Aims. The aim of this study was to compare the surgical and quality-of-life outcomes of children with skeletal dysplasia to those in children with idiopathic early-onset scoliosis (EOS) undergoing growth-friendly management. Patients and Methods. A retrospective review of two prospective multicentre EOS databases identified 33 children with skeletal dysplasia and EOS (major curve ≥ 30°) who were treated with growth-friendly instrumentation at younger than ten years of age, had a minimum two years of postoperative follow-up, and had undergone three or more lengthening procedures. From the same registries, 33 matched controls with idiopathic EOS were identified. A total of 20 children in both groups were treated with growing rods and 13 children were treated with vertical expandable prosthetic titanium rib (VEPTR) instrumentation. Results. Mean preoperative major curves were 76° (34° to 115°) in the skeletal dysplasia group and 75° (51° to 113°) in the idiopathic group (p = 0.55), which were corrected at final follow-up to 49° (13° to 113°) and 46° (12° to 112°; p = 0.68), respectively. T1-S1 height increased by a mean of 36 mm (0 to 105) in the skeletal dysplasia group and 38 mm (7 to 104) in the idiopathic group at the index surgery (p = 0.40), and by 21 mm (1 to 68) and 46 mm (7 to 157), respectively, during the distraction period (p = 0.0085). The skeletal dysplasia group had significantly worse scores in the physical function, daily living, financial impact, and parent satisfaction preoperatively, as well as on financial impact and child satisfaction at final follow-up, than the idiopathic group (all p < 0.05). The domains of the 24-Item Early-Onset Scoliosis Questionnaire (EOSQ24) remained at the same level from preoperative to final follow-up in the skeletal dysplasia group (all p > 0.10). Conclusion. Children with skeletal dysplasia gained significantly less spinal growth during growth-friendly management of their EOS and their health-related quality of life was significantly lower both preoperatively and at final follow-up than in children with idiopathic EOS. Cite this article: Bone Joint J 2019;101-B:1563–1569

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

Purpose. This report compares midterm results of open neck osteoplasty + neck osteotomy vs arthroscopic osteoplasty for severe Slipped Capital Femoral Epiphysis (SCFE). Method. Database from 2006 to 2013 identified 22 patients out of 187 operations for SCFE. 12 underwent Open Neck Osteotomy (ONO) and osteoplasty by Ganz surgical dislocation approach. 10 underwent Arthroscopic Osteoplasty (AO). The mean follow-up for the ONO and AO groups were 59 (46 – 70), 36.1 (33 – 46) months respectively. Results. The unpaired t-test showed that the post-operative corrections were significantly better in the ONO than the AO group. Slip angle (16.7° (1°–28.6°) Vs 47.1° (40.2° – 53.5°) p = .0003), head neck offset correction (5mm (2–13mm) Vs 0mm (0mm – 2mm) p = 0.0003), alpha angle (34.6° (23.2°–45.6°) Vs 61.88° (52.1° – 123°) p= 0.0003), Modified Harris Hip Score (MHHS) (90(86.2–99) Vs 75.5 (58.75 – 96.8) p= 0.003) and internal rotation p= 0.0002. Paired t-test showed significant improvement in corrections within the individual groups compared with their own preoperative values. The results of AO group were oblique plane slip angle (55° (47.7° – 63.2°) Vs 47.1° (40.2° – 53.5°) p= 0.001), alpha angle (90.7° (65° – 131°) Vs 61.88° (52.1° – 123°) p= 0.0001), head neck offset (0mm (−3 mm to 0mm) Vs 0mm (0mm – 2mm) p= 0.001) and MHHS (52.7 (28.7 – 89.1) Vs 75.5 (58.75 – 96.8) p= 0.0005). Complications in ONO group were varus malunion (1) and non-union(1) of the osteotomy. In the arthroscopic group persistent impingement in 3 patients and 5 were not able to return to sports. Conclusion. Our results showed improved hip function following arthroscopic osteoplasty in severe SCFE. Considering the risks of an open surgical dislocation we could find that arthroscopy contributed worthy improvement in hip function in low demand patients

Aim. A prospective study to report the results of using gentamycin-collagen in the surgical treatment of osteomyelitis. Materials and Methods. After complete radiological and laboratory studies, empirical systemic Imipenem antibiotic was started pre-operatively followed by radical operation and implantation of Collatamp-EG®. Bone defects were treated with iliac or composite ceramic bone graft. Primary or secondary soft tissue reconstructive procedures were used. Closed gravitational suction drainage was used. Parental systemic antibiotics were continued for 2–3 weeks according to culture sensitivity results followed by oral therapy for another 4 weeks. Cattaneo et al scoring system was used to evaluate the final bony and functional results. Results. The mean number of Collatamp-EG® sponges implanted per patient were 3.6 and the mean follow-up period was 3.8 years. 85.7% of patients had showed positive cultures and staphylococcus aureus was the commonest cultured organism. The following complications were reported; pathological fracture (1), malnuion (2), nonunion (1). According to Cattaneo et al scoring system, bone healing was achieved in 94.4% of patients; bone infection control without relapse was achieved in 100% of patients. 89.2% of patients had complete functional recovery. Conclusions. Local antibiotic delivery system seems to be a useful and safe component in the armamentarium of the orthopedic surgeon dealing with bone infection by maximizing the local concentration while minimizing their systemic toxicity. Collatamp-EG® help bone and soft tissue repair without the need to remove it

Purpose

To establish the early outcome, satisfaction and complications of sinus tarsi implants in the management of symptomatic flexible flatfeet for a paediatric population

Purpose. To determine whether radiographically demonstrated femoral neck irregularities (pistolgrip-deformity, focal prominences or lytic defects) are associated with positive clinical impingement tests. Methods. The 1989 Bergen birth cohort (n=4004) was invited to a population-based follow-up including clinical examination and two pelvic radiographs. 2081 (52%) were enrolled. Associations between clinical and radiographic findings were examined using chi-squared or Fischer's exact test. Results. Radiographs from 1193, 18-19 year olds, (42% males) have been analysed. For males, irregularities were seen in 128/501 (15.5%) right and 149/501 (19.7%) left hips, of which 13 (10.2%) and 12 (8.1%) had a positive impingement-test respectively (p-values 0.06 and 0.04). The pistolgrip-deformity was seen in 15.8% of right and 19.4% of left hips, of which 6.3% and 7.2% had a positive impingement-test, respectively (p-values 0.6 and 0.3); the focal prominence in 9.2% right and 10% left hips, of which 15.2% and 4% had a positive impingement-test (p-values 0.008 and 0.74) and the lytic defect in 7% right and 8.8% left hips, of which 14.3% and 9.1% had a positive impingement-test (p-values 0.053 and 0.19). For females, irregularities were seen in 34/692 (4.9%) right hips and 46/692 (6.6%) left hips, of which 0 and 2 (4.3%) had a positive impingement-test (p-values 1 and 0.65). Each irregularity was seen in 2-3% of both right and left hips, with no positive impingement tests on the right side and one positive test for each left side, yielding p-values from 0.45 to 1. Conclusion. Femoral neck irregularities are common and symmetrical findings in young males, and are associated with a positive impingement-test. A focal right-sided prominence is associated with a positive test. These radiological findings seem to be less common, but symmetrical, in young females, but without any association with a positive impingement-test

Introduction:. Risk factors for developmental dysplasia of the hip (DDH) in early infancy have never been validated from basic principles; their relevance remains controversial. Purpose:. To determine risk factors for DDH using newly developed diagnostic criteria based on international consensus. Methods:. In this population-based cohort study, 9904 babies born at a secondary care unit (2010–2012) received a standardised examination (usually within 24 hours postpartum) in which we prospectively ascertained the presence of the common risk factors for DDH (breech, family history, etc). Infants exhibiting ≥1 factor were eligible and underwent ultrasound testing within 8 weeks. Alpha angles were measured by surgeon/radiologist in consensus and blinded to risk factors and age. Using multivariable methods we evaluated the association of the risk factors and ultrasonographic DDH using criteria based on international consensus. Results:. 1766 (18%) newborns exhibited ≥1 risk factor for DDH. Of these 1489 (84%) infants participated. To date, 1296 (87%) completed the ultrasound at a mean age of 8±3 weeks. Of the 1296, 55 (4%) patients exhibited alpha <55° and 43 (3%) exhibited alpha <50°. Of all risk factors, only female gender was associated with an alpha <55° (RR=2; 95% CI=1.1, 3.5; p=.01). In contrast, abnormal clinical examination findings of the hip were strongly associated with DDH (p<.0001). Conclusion:. In a prospective study using robust case definitions, commonly known risk factors were not clinically important markers of DDH when DDH was defined by consensus criteria. Given the generally poor and conflicting evidence on risk factors for DDH, our preliminary results suggest a new approach is needed in the risk prediction of DDH. Level of evidence: I

Aim. Congenital Talipes Equinovarus (CTEV) has been excluded from the standards set by the NHS fetal anomaly screening programme (NHS FASP) for the 18. +0. –20. +6. week fetal ultrasound scan (USS). Whilst adhering to NHS FASP guidelines, the antenatal ultrasound department at our centre performs “incidental screening” for CTEV; parents are informed if CTEV is noted incidentally during the scan and referral made to the fetal medicine department. Our aim was to investigate the effectiveness of incidental antenatal screening for structural CTEV. Method. The database of the antenatal ultrasound department was interrogated for all suspected cases of CTEV on the 18. +0. –20. +6. week USS, between August 2006 and June 2012. Terminations, stillbirths and outside referrals were excluded. Our Ponseti-service database was searched to identify all patients treated for structural CTEV between January 2007 and November 2012. Cases were excluded if the mother did not receive antenatal-care at our centre. Results from the two searches were cross-referenced, and statistical analysis performed. Results. 30077 18. +0. –20. +6. week USS were performed on 24282 patients, with CTEV diagnosed in 74 patients. After exclusions, there were 39 patients. 54 patients were treated for structural CTEV with 37 patients (54 feet, CTEV-incidence 0.001) after exclusions; 25 (67.5%) diagnosed pre-natally (15 unilateral, 10 bilateral), and 12 (32.5%) diagnosed post-natally (5 unilateral, 7 bilateral). Sensitivity of screening for CTEV was 67.5%, specificity 99.8%, positive predictive value (PPV) 64.1% and negative predictive value 99.9%. The proportion of cases detected antenatally has reduced since introduction of NHS-FASP. Conclusion. This data is important and necessary to comprehensively counsel our patients. We are unable to find similar contemporary data from other units within the NHS for comparison. NHS-FASP guidelines seem to have reduced the efficacy of antenatal detection of CTEV at our unit, and further prospective study is required to determine the value of screening for patients

Aim. To compare the rate and severity of avascular necrosis following medial open and closed reduction in developmental hip dysplasia and the resulting influence on femoral and acetabular development. Method. The radiographs and hospital records of 118 patients with dislocation of the hip were reviewed. 57 patients (66 hips) underwent medial open reduction and 61 patients (75 hips) underwent closed reduction. Mean follow-up was 10.9 years (5 years to 17.4 years). Avascular necrosis (AVN) was recorded according to the Bucholz and Ogden classification. The acetabular index was measured pre-operatively, at 1 and 4 years following surgery. The final radiograph was assigned a Severin grade. Sharp and centre-edge angles were recorded at final follow-up. A Severin grade I or II was considered a satisfactory result and a grade III to V an unsatisfactory result. Initial non-operative measures, such as Pavlik harness treatment and traction were documented. Additional surgical interventions were noted. Results. The rate of clinically significant AVN (types 2, 3, 4) following medial open reduction was 28.7% versus 17.3% following closed reduction. The rate of Type 2 AVN was 22.7% versus 10.6% respectively. Early acetabular development was similar in both groups. Long-term follow-up showed an unsatisfactory outcome (Severin grade III-V) following medial open reduction in 32% versus 8% in the closed reduction group. Conclusion. Our findings suggest that medial open reduction is associated with a higher rate of AVN than closed reduction. Type 2 AVN was twice as common in the medial open reduction group. More unsatisfactory results were seen in the medial open reduction group at long term follow up

This study aimed to determine the major diagnoses and needs of children in Rwanda with musculoskeletal conditions to enable the Rwandan government to begin to plan orthopaedic and rehabilitation services. BACKGROUND. When faced with developing orthopaedic services for children in Sub-Saharan Africa, there is little objective evidence-based data on the magnitude and type of services needed. Rwanda is a small country that is in the process of developing orthopaedic and rehabilitation services, and its Ministry of Health supported a survey that would provide information necessary for planning such services. METHODS. A national survey of musculoskeletal impairment (MSI) prevalence was undertaken. Of a population of 8.4 million, 8368 people were enumerated. Four thousand one hundred thirty-four were aged 16 years or less. Cases who failed a screening test for MSI were examined, allocated a diagnostic category, and assessed as to treatment needed. RESULTS. Of 4134 people aged 16 years or less who were enumerated, 3526 (85%) were screened and 91 had MSI, giving a prevalence of MSI among children of 2.58% (95% confidence interval; 2.06-3.10). Twenty-three percent of MSIs were a result of congenital deformity, 14% neurologic conditions, 12% trauma, 3% infection, and 46% other acquired pathology. Of the MSIs, 56.7% were mild, 37.8% moderate, and 5.6% severe. Extrapolated treatment needs suggest that 2% of Rwandan children (approximately 80,000) need orthopaedic physical therapy, 1.2% (50,000) need orthopaedic surgery, and approximately 10,000 need orthopaedic appliances. CONCLUSIONS. These results will be of use in planning future paediatric orthopaedic services in Rwanda, and for comparative studies in other low-income countries

We report the radiological outcomes, and short-term clinical results, of 47 periacetabular osteotomies undertaken through both the traditional bikini incision, and a minimally invasive approach.

47 periacetabular osteotomies have been undertaken in 45 patients, by the senior author, between 2005 and 2013. There were 10 male and 35 female patients. The mean age at operation was 28.2 years. Since 2010 surgery has been performed through a 7-cm skin incision (31 hips), an incision coined as minimally invasive by Søballe et al when they described their trans-sartorial approach for acetabular surgery. Clinical data was collected prospectively; primary outcome measures included the young adult hip score and the hip disability and osteoarthritis outcome score. Pre- and post-operative radiographs were analysed for achieved acetabular reorientation.

At the time of follow-up the median young adult hip score had improved significantly from pre-operative values. Mean scores were 35.4 pre-operatively, and 64.25 post-operatively. Improvement in the anterior and lateral centre-edge angle was 32 and 32.9 degrees respectively through a traditional incision, and 27.1 and 30 degrees through the minimally invasive approach (p>0.05). No major complications occurred in any patient. Four patients complained of lateral cutaneous nerve hypoaesthesia, in two patients there was delayed union of the pubic osteotomy and in one non-union. Two patients have gone on to total hip replacement.

The minimally invasive approach is safe and allows for accurate reorientation of the acetabulum whilst minimizing tissue damage. The scar is cosmetically appealing to patients, especially the predominantly female group treated with this condition. We did not see the evidence of reduced surgical stay that has been reported by other groups utilizing a minimally invasive approach.

Level of evidence: II

The aim was to assess contemporary management of slipped capital femoral epiphysis (SCFE) by surveying members of the British Society of Children's Orthopaedic Surgery (BSCOS).

A questionnaire with 5 case vignettes was used. Two questions examined the timing of surgery for an acute unstable SCFE in a child presenting at 6 hours and at 48 hours after start of symptoms. Two further questions explored the preferred method of fixation in mild and severe stable SCFE. The final question examined the management of the contralateral normal hip. Responses were entered into an Excel spreadsheet and the data w analysed using a chi-squared test.

The response rate was 56% (110/196). 88.2% (97/110) responded that if a child presented with an acute unstable SCFE within 6 hours, they would treat it within 24 hours of presentation, compared with 40.9% (45/110) for one presenting 48 hours after the onset of symptoms (P<0.0001). 52.6% (58/110) of surveyed BSCOS members would offer surgery for an unstable SCFE between 1 and 7 days after onset of symptoms. Single screw fixation in situ was advocated by 96.4% (106/110) and 70.9% (78/110) while corrective osteotomy was preferred by 1.8% (2/110) and 26.4% (29/110) of respondents for the mild and the severe stable slips respectively (P<0.0001). Surgeons preferring osteotomy are more likely to perform an intracapsular technique. Prophylactic fixation of the contralateral normal hip was performed by 27.3% (30/110) of participants.

There are significant differences in opinions between BSCOS members as to the optimal management of SCFE in children. This reflects the variable recommendations and quality in the current scientific literature. Further research is therefore required to determine best practice and enable consensus to be reached.

We reviewed the long-term results of the treatment of slipped upper femoral epiphysis (SUFE) using realignment procedures in 36 patients (37 hips) at an average follow-up of 33.8 years (26 to 42). There were serious short-term complications in seven of the 22 hips treated by subcapital osteotomy, three of the 11 hips treated by intertrochanteric osteotomy and three of the four hips treated by manipulative reduction.

At re-examination, the clinical and radiological results were excellent or good in 41% of the hips treated by subcapital osteotomy, in 36% treated by intertrochanteric osteotomy and in none treated by manipulative reduction. In all, seven hips (19%) had had arthrodesis or total hip replacement.

The natural history of SUFE was probably not improved by any of the treatments used in our study. We therefore discourage the use of subcapital and intertrochanteric osteotomy as well as manipulative reduction in the primary treatment of chronic SUFE.

Aims. 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. Methods. We randomized feet from children aged below 36 months with idiopathic clubfoot on a 1:1 basis in either the blade or needle group. Follow-up was conducted at three weeks and three months postoperatively, where dorsiflexion range, Pirani scores, and complications were recorded. The noninferiority margin was set at 4° difference in dorsiflexion range at three months postoperatively. Results. The blade group had more dorsiflexion at both follow-up consultations: 18.36° versus 18.03° (p = 0.115) at three weeks and 18.96° versus 18.26° (p = 0.001) at three months. The difference of the mean at three months 0.7° is well below the noninferiority margin of 4°. There was no significant difference in Pirani scores. The blade group had more extensive scar marks at three months than the needle group (8 vs 2). No major complications were recorded. Conclusion. The needle tenotomy is noninferior to the blade tenotomy for usage in Ponseti treatment for idiopathic clubfoot in children aged below 36 months. Cite this article: Bone Joint J 2024;106-B(8):871–878

Aims. To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically. Methods. A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples t-test, chi-squared test, and logistic regression analysis were used to identify the risk factors associated with unsuccessful RHR. Results. Redislocation occurred during surgery in 48 patients (23%), and during follow-up in 44 (21.1%). The mean follow-up of patients with successful RHR was 13.25 months (6 to 78). According to the univariable analysis, time from injury to surgery (p = 0.002) and preoperative dislocation distance (p = 0.042) were identified as potential risk factors for unsuccessful RHR. However, only time from injury to surgery (p = 0.007) was confirmed as a risk factor by logistic regression analysis. Receiver operating characteristic curve analysis and chi-squared test confirmed that a time from injury to surgery greater than 1.75 months increased the rate of unsuccessful RHR above the cutoff (p = 0.002). Conclusion. Time from injury to surgery is the primary independent risk factor for unsuccessful RHR in surgically treated children with CMFs, particularly in those with a time from injury to surgery of more than 1.75 months. No other factors were found to influence the incidence of unsuccessful RHR. Surgical reduction of paediatric CMFs should be performed within the first two months of injury whenever possible. Cite this article: Bone Jt Open 2024;5(7):581–591

Aims. 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%. Methods. We retrospectively included all newborns referred for ultrasound screening at our institution based on primary risk factor, clinical, and PFD screening. α angles, PFD, FHC, and FHC at follow-up ultrasound for referred newborns were measured and compared using scatter plots, linear regression, paired t-test, and box-plots. Results. We included 2,735 newborns, of whom 754 received a follow-up hip ultrasound within six weeks of age. After exclusion, 1,500 hips were included for analysis. Sex distribution was 372 male and 380 female, and the mean age at examination was 36.6 days (4 to 87). We found a negative linear correlation of PFD to α angles (p < 0.001), FHC (p < 0.001), and FHC during provocation (p < 0.001) with a 1 mm increase in PFD corresponding to a -2.1° (95% confidence interval (CI) -2.3 to -1.9) change in α angle and a -3.4% (95% CI -3.7 to -3.0) change in FHC and a -6.0% (-6.6 to -5.5) change in FHC during provocation. The PFD was significantly higher with increasing Graf types and in displaceable hips (p < 0.001). Conclusion. PFD is strongly correlated to both α angles and hip displaceability, as measured by FHC and FHC during provocation, in ultrasound of newborn hips. The PFD increases as the hips become more dysplastic and/or displaceable. Cite this article: Bone Jt Open 2023;5(1):3–8

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. Within healthcare, several measures are used to quantify and compare the severity of health conditions. Two common measures are disability weight (DW), a context-independent value representing severity of a health state, and utility weight (UW), a context-dependent measure of health-related quality of life. Neither of these measures have previously been determined for developmental dysplasia of the hip (DDH). The aim of this study is to determine the DW and country-specific UWs for DDH. Methods. A survey was created using three different methods to estimate the DW: a preference ranking exercise, time trade-off exercise, and visual analogue scale (VAS). Participants were fully licensed orthopaedic surgeons who were contacted through national and international orthopaedic organizations. A global DW was calculated using a random effects model through an inverse-variance approach. A UW was calculated for each country as one minus the country-specific DW composed of the time trade-off exercise and VAS. Results. Over a four-month period, 181 surgeons participated in the survey, with 116 surgeons included in the final analysis. The global DW calculated to be 0.18 (0.11 to 0.24), and the country-specific UWs ranged from 0.26 to 0.89. Conclusion. This is the first time that a global disability weight and country-specific utility weights have been estimated for DDH, which should assist in economic evaluations and the development of health policy. The methodology may be applied to other orthopaedic conditions. Cite this article: Bone Jt Open 2023;4(3):120–128

Aims. A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening. Methods. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group. Results. A total of 60 statements were graded by 128 clinicians in the first round and 132 in the second round. Consensus was reached on 30 out of 60 statements in the first round and an additional 12 in the seond. This was summarized in a consensus statement and distilled into a flowchart to guide clinical practice. Conclusion. We identified agreement in an area of medicine that has a long history of controversy and varied practice. None of the areas of consensus are based on high-quality evidence. This document is thus a framework to guide clinical practice and on which high-quality clinical trials can be developed. Cite this article: Bone Joint J 2023;105-B(2):209–214

Aims. Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options. Methods. A systematic literature search in healthcare databases (PubMed, Embase, the Cochrane library, CINAHL, and Web of Science) was performed from January 2000 to July 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The quality of the included studies was assessed with the Cochrane ROBINS-I risk of bias tool. Relevant trials studying BPBP with at least five years of follow-up and describing functional outcome were included. Results. Of 5,941 studies, 19 were included after full-text screening. A total of 15 surgical techniques were described. All studies described an improvement in active external rotation (range 12° to 128°). A decrease in range of motion and Mallet score after long-term (five to 30 years) follow-up compared to short-term follow-up was seen in most studies. Conclusion. The literature reveals that functional outcome increases after different secondary procedures, even in the long term. Due to the poor methodological quality of the included studies and the variations in indication for surgery and surgical techniques described, a consensus on the long-term functional outcome after secondary surgical procedures in BPBP patients cannot be made. Cite this article: Bone Joint J 2023;105-B(4):455–464