Aims. Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app). Methods. A total of 20 pelvis radiographs (40 hips) were used to measure MP by using the HS app. Measurements were performed by five different members of the multidisciplinary team, with varying levels of expertise in MP measurement. The same measurements were repeated two weeks later. A senior orthopaedic surgeon measured the MP on picture archiving and communication system (PACS) as the gold standard and repeated the measurements using HS app. Pearson’s correlation coefficient (r) was used to compare PACS measurements and all HS app measurements and assess validity. Intraclass correlation coefficient (ICC) was used to assess intra- and inter-rater reliability. Results. All HS app measurements (from 5 raters at week 0 and week 2 and PACS rater) showed highly significant correlation with the PACS measurements (p < 0.001). Pearson’s correlation coefficient (r) was constantly over 0.9, suggesting high validity. Correlation of all HS app measures from different raters to each other was significant with r > 0.874 and p < 0.001, which also confirms high validity. Both inter- and intra-rater reliability were excellent with ICC > 0.9. In a 95% confidence interval for repeated measurements, the deviation of each specific measurement was less than 4% MP for single measurer and 5% for different measurers. Conclusion. The HS app provides a valid method to measure hip MP in CP, with excellent inter- and intra-rater reliability across different medical and allied health specialties. This can be used in hip surveillance programmes by interdisciplinary measurers. Cite this article: Bone Jt Open 2023;4(5):363–369

The databases of the Picture Archiving and Communication Systems of two hospitals were searched and all children who had a lateral radiograph of the ankle during their attendance at the emergency department were identified. In 227 radiographs, Bohler’s and Gissane’s angles were measured on two separate occasions and by two separate authors to allow calculation of inter- and intra-observer variation. Intraclass correlation coefficients were used to assess the reliability of the measurements. For Bohler’s angle the overall inter-observer reliability, the intraclass correlation coefficient was 0.90 and the intra-observer reliability 0.95, giving excellent agreement. This reliability was maintained across the age groups. For Gissane’s angle, inter- and intra-observer reliability was only fair or poor across most age groups. Further analysis of the Bohler’s angle showed a significant variation in the mean angle with age. Contrary to published opinion, the angle is not uniformly lower than that of adults but varies with age, peaking towards the end of the first decade before attaining adult values. The age-related radiologic changes presented here may help in the interpretation of injuries to the hindfoot in children

Purpose. The purpose of this study was to analyse inter- and intra-rater reliability of the Head-Shaft angle (HSA) on radiographs from a surveillance programme for children with cerebral palsy (CP). Method. A high HSA is a risk factor for hip displacement in children with CP. To evaluate inter- and intra-rater reliability of the HSA, hip radiographs from the CP surveillance programme CPUP in the southern part of Sweden during the first half of 2016 were included in this study. Results. We analysed 50 radiographs from children in Gross Motor Function Classification System (GMFCS) levels II-V with a mean age of 6.6 (SD 3.2) years from 11 different radiology departments. Three raters measured the HSA of one hip at baseline and after four weeks. Intra-Class Correlation Coefficient (ICC) showed excellent inter- and intra-rater reliability of the HSA with ICC 0.92 (95% CI 0.87–0.96) and ICC 0.99 (95% CI 0.98–0.99) respectively. Conclusion. We conclude that the HSA, important when predicting hip displacement in CP, showed high inter-and intra-rater reliability when analysed on radiographs from various radiology departments in a surveillance program for CP

The aim was to determine reliability in treatment threshold based on USS angular measurements between observers involved in the DDH hip screening programme at the NOC and assess the effect of image orientation on the accuracy of these measurements. 3 independent observers measured alpha and beta angles on bilateral hips in 10 consecutive patients seen in the DDH hip screening clinic. All scans were performed by a single radiographer and observers used the same set of USS images for a given patient. Each observer measured alpha and beta angles a total of 4 times: conventional ultrasound image projection (with the ilium horizontal) (round 1), Graf's anatomical projection (round 2), and both techniques repeated 1 month later (round 3 and 4 respectively) to assess intra-observer reliability. To determine its effect on treatment threshold taking into account alpha and beta angles and patient's age, the consistency between observers' management recommendations was evaluated for each round. Possible outcomes were: 1) patient discharged, 2) no treatment needed yet, but follow-up required, 3) start treatment. Intra-observer reliability for conventional projection was moderate (Kappa 0.58), and improved for anatomical projection (Kappa 0.65). Inter-observer reliability, as a surrogate measure of consistency in management recommendations between observers, ranged from fair to moderate across the 4 rounds (Kappa 0.30 – 0.50). However, contrary to previous recommendations, reliability was better with conventional projection (Kappa 0.41 (95% CI 0.11–0.72)) compared to anatomical projection (Kappa 0.36 (95% CI −0.01–0.73)). The overall agreement in management recommendations, pooling all results across 4 rounds, was 51.3% (Kappa 0.39 (95%CI 0.15–0.63)). This audit supports the argument that anatomical image projection improves intra-observer consistency. However, as with all USS measurements, angular measurements were highly user dependent and treatment threshold based on USS may not be as consistent as anticipated

We have evaluated the reliability of the measurement of radiological indicators in developmental dysplasia of the hip. Three observers each independently assessed 60 pelvic radiographs from infants aged from 3 to 36 months. Errors from the true value of a single measurement made by a single observer (E1), of the average of two measurements by a single observer (E2), and of the average of two single measurements by two different observers (E3) were established for the acetabular index of Hilgenreiner, for the assessment of superior and lateral femoral displacement and for indicators of pelvic alignment. The errors for the assessment of the acetabular index were E1 ± 5°, E2 ± 5°, and E3 ± 3.5°. There was a significant correlation between the presence of an acetabular notch on the radiograph and an increased error in measurement (p = 0.01). Yamamuro’s measurement of lateral femoral displacement was more reliable than the Hilgenreiner distance. The errors of indicators of pelvic alignment showed a correlation with the age of the infant; the quotient of pelvic rotation was more reliable after seven months of age (p < 0.0001). The errors of the measurement of the symphysis os-ischium angle tended to increase with age and those of the measurement of the index of pelvic tilt decreased with skeletal maturation (p = 0.002)

The purpose of our study was to independently assess the modified Herring lateral pillar classification.

Aims. The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. Methods. This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. Results. Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). Conclusion. The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP. Cite this article: Bone Jt Open 2023;4(8):580–583

Aims. The aim of this study was to investigate the agreement in interpretation of the quality of the paediatric hip ultrasound examination, the reliability of geometric and morphological assessment, and the relationship between these measurements. Methods. Four investigators evaluated 60 hip ultrasounds and assessed their quality based the standard plane of Graf et al. They measured geometric parameters, described the morphology of the hip, and assigned the Graf grade of dysplasia. They analyzed one self-selected image and one randomly selected image from the ultrasound series, and repeated the process four weeks later. The intra- and interobserver agreement, and correlations between various parameters were analyzed. Results. In the assessment of quality, there a was moderate to substantial intraobserver agreement for each element investigated, but interobserver agreement was poor. Morphological features showed weak to moderate agreement across all parameters but improved to significant when responses were reduced. The geometric measurements showed nearly perfect agreement, and the relationship between them and the morphological features showed a dose response across all parameters with moderate to substantial correlations. There were strong correlations between geometric measurements. The Graf classification showed a fair to moderate interobserver agreement, and moderate to substantial intraobserver agreement. Conclusion. This investigation into the reliability of the interpretation of hip ultrasound scans identified the difficulties in defining what is a high-quality ultrasound. We confirmed that geometric measurements are reliably interpreted and may be useful as a further measurement of quality. Morphological features are generally poorly interpreted, but a simpler binary classification considerably improves agreement. As there is a clear dose response relationship between geometric and morphological measurements, the importance of morphology in the diagnosis of hip dysplasia should be questioned. Cite this article: Bone Joint J 2023;105-B(10):1123–1130

Aims. Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs. Methods. A PROSPERO-registered systematic literature review was performed following PRISMA guidelines. All relevant studies published until January 2023 were identified. Individual outcomes and outcome measurement tools were extracted verbatim. The measurement tools were assessed for reliability and validity, and all outcomes were grouped according to the Outcome Measures Recommended for use in Randomized Clinical Trials (OMERACT) filters. Results. From 91 eligible studies, 27 individual outcomes were identified, including those related to clinical assessment (n = 12), mobility (n = 4), adverse events (n = 6), investigations (n = 4), and miscellaneous (n = 1). Ten outcome measurement tools were identified, of which Hoffer’s Functional Ambulation Scale was the most commonly used. Several studies used unvalidated measurement tools originally developed for other conditions, and 26 studies developed new measurement tools. On the OMERACT filter, most outcomes reported pathophysiology and/or the impact on life. There were only six patient- or parent-reported outcomes, and none assessed the quality of life. Conclusion. The outcomes that were reported were heterogenous, lack validation and failed to incorporate patient or family perceptions. Until outcomes can be reported unequivocally, research in this area will remain limited. Our findings should guide the development of a core outcome set, which will allow consistency in the reporting of outcomes for this condition. Cite this article: Bone Joint J 2024;106-B(3):277–285

Aims. Though the pathogenesis of Legg-Calve-Perthes disease (LCPD) is unknown, repetitive microtrauma resulting in deformity has been postulated. The purpose of this study is to trial a novel upright MRI scanner, to determine whether any deformation occurs in femoral heads affected by LCPD with weightbearing. Methods. Children affected by LCPD were recruited for analysis. Children received both standing weightbearing and supine scans in the MROpen upright MRI scanner, for coronal T1 GFE sequences, both hips in field of view. Parameters of femoral head height, width, and lateral extrusion of affected and unaffected hips were assessed by two independent raters, repeated at a one month interval. Inter- and intraclass correlation coefficients were determined. Standing and supine measurements were compared for each femoral head. Results. Following rigorous protocol development in healthy age-matched volunteers, successful scanning was performed in 11 LCPD-affected hips in nine children, with seven unaffected hips therefore available for comparison. Five hips were in early stage (1 and 2) and six were in late stage (3 and 4). The mean age was 5.3 years. All hips in early-stage LCPD demonstrated dynamic deformity on weightbearing. Femoral head height decreased (mean 1.2 mm, 12.4% decrease), width increased (mean 2.5 mm, 7.2% increase), and lateral extrusion increased (median 2.5 mm, 23% increase) on standing weightbearing MRI compared to supine scans. Negligible deformation was observed in contra-lateral unaffected hips, with less deformation observed in late-stage hips. Inter- and intraclass reliability for all measured parameters was good to excellent. Conclusion. This pilot study has described an effective novel research investigation for children with LCPD. Femoral heads in early-stage LCPD demonstrated dynamic deformity on weightbearing not previously seen, while unaffected hips did not. Expansion of this protocol will allow further translational study into the effects of loading hips with LCPD. Cite this article: Bone Joint Open 2020;1-7:364–369

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.

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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.

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This study aimed to evaluate the relationship between hip shape and mid-term function in Perthes’ disease. It also explored whether the modified three-group Stulberg classification can offer similar prognostic information to the five-group system.

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The gold standard for percutaneous Achilles tendon tenotomy during the Ponseti treatment for idiopathic clubfoot is a tenotomy with a No. 15 blade. This trial aims to establish the technique where the tenotomy is performed with a large-bore needle as noninferior to the gold standard.

We have tested the reliability of a recently reported classification system of hip morphology in adolescents with cerebral palsy in whom the triradiate cartilage was closed. The classification is a six-grade ordinal scale, based on the measurement of the migration percentage and an assessment of Shenton’s arch, deformity of the femoral head, acetabular deformity and pelvic obliquity. Four paediatric orthopaedic surgeons and four physiotherapists received training in the use of the classification which they applied to the assessment of 42 hip radiographs, read on two separate occasions. The inter- and intra-observer reliability was assessed using the intraclass correlation coefficient and found to be excellent, with it ranging from 0.88 to 0.94. The classification in our study was shown to be valid (based on migration percentage), and reliable. As a result we believe that it can now be used in studies describing the natural history of hip displacement in cerebral palsy, in outcome studies and in communication between clinicians

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Studies of infant hip development to date have been limited by considering only the changes in appearance of a single ultrasound slice (Graf’s standard plane). We used 3D ultrasound (3DUS) to establish maturation curves of normal infant hip development, quantifying variation by age, sex, side, and anteroposterior location in the hip.

Aim. Our aim was to compare the Wilkins'-modified Gartland classification and AO classifications of supracondylar humeral fracture with respect to: -Inter-observer reliability; Association of fracture-grade with radiological quality of reduction; Association of fracture-grade with complications. Methods. The unit database was interrogated to identify all operated supracondylar fractures between 2007–2011. Radiographs from each case were evaluated by four observers (three consultants, one trainee) and classified according to Gartland and the AO system. Inter-observer reliability was calculated using Cohen's Kappa coefficient. Radiological quality of reduction was evaluated using a new scoring system, combining the anterior humeral line, the lateral capitello-humeral angle (LCHA) and Baumann's angle, (compared to reference values). Analysis of variance (ANOVA) was performed to determine whether there was a statistically significant difference in scores between the fracture grades. Case notes were reviewed for pre- and post-operative complication, and chi-squared test performed to compare the incidence between different fracture grades. Results. 83 cases were identified for fracture classification and 66 for assessment of reduction and complications. Inter-observer reliability was 0.58 for Gartland (moderate agreement), and 0.70 for the AO classification (good agreement). ANOVA demonstrated no significant difference in the overall reduction scores between the different grades of either classification. Mean scores for LCHA were lower for Gartland-2b (p=0.02) and AO-3 (p=0.007) groups (compared to Gartland-3 and AO-4). Complications were more frequent with the higher grades of fracture in both classifications (p<0.05). Conclusion. The AO classification has greater reliability and should be considered as an alternative to the Gartland classification. A higher grade of fracture is not associated with inferior radiographic outcomes. Surgeons should be aware that restoration of the LCHA is more difficult with the Gartland-2b and AO-3 fractures, probably because of the intact posterior cortex. A greater rate of complications should be expected with higher grades of fracture

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The present study seeks to investigate the correlation of pubofemoral distances (PFD) to α angles, and hip displaceability status, defined as femoral head coverage (FHC) or FHC during manual provocation of the newborn hip < 50%.

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The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

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Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing.