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. We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes. Methods. A systematic search of PubMed, Embase, The Cochrane Library, OrthoSearch, and Web of Science from the date of inception of each database until 27 March 2022 was performed. The primary outcome of interest was the prevalence of late detection of DDH, diagnosed after three months. Secondary outcomes of interest were the prevalence of abduction bracing treatment and surgical procedures performed in childhood for dysplasia. Only studies describing the primary outcome of interest were included. Results. A total of 31 studies were identified, of which 13 described universal screening and 20 described selective screening. Two studies described both. The prevalence of late DDH was 0.10 per 1,000 live births (95% confidence interval (CI) 0.00 to 0.39) in the universal screening group and 0.45 per 1,000 live births (95% CI 0.31 to 0.61) in the selective screening group. Abduction bracing treatment was performed on 55.54 per 1,000 live births (95% CI 24.46 to 98.15) in the universal screening group versus 0.48 per 1,000 live births (95% CI 0.07 to 1.13) in the selective screening group. Both the universal and selective screening groups had a similar prevalence of surgical procedures in childhood for dysplasia being performed (0.48 (95% CI 0.32 to 0.63) vs 0.49 (95% CI 0.31 to 0.71) per 1,000 live births, respectively). Conclusion. Universal screening showed a trend towards lower prevalence of late DDH compared to selective screening. However, it was also associated with a significant increase in the prevalence of abduction bracing without a significant reduction in the prevalence of surgical procedures in childhood for dysplasia being performed. High-quality studies comparing both treatment methods are required, in addition to studies into the natural history of missed DDH. Cite this article: Bone Joint J 2023;105-B(2):198–208

The February 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures.

The non-operative treatment of idiopathic clubfoot has become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular as a result of published short and long-term success rates in North America. Non-compliance with abduction bracing has been proven to be a major risk factor for recurrence of clubfoot. The purpose of this retrospective study was to identify those patients who were non-compliant with the abduction bracing post casting and to then assess the rate and severity of recurrence. One-hundred and fifty children (184 feet) with unilateral or bilateral clubfoot who were treated with the Ponseti method by the senior author from 1999 to 2008 were reviewed. We identified those patients who were non-compliant with the abduction bracing. Compliance was defined as three months full time wear followed by twelve months night-time/nap-time wear. Recurrence was classified as minor, defined as those requiring an extra-articular surgical procedure and major, requiring an intra-articular procedure. We identified fifty children with seventy clubfeet who were followed up for a minimum of 12 months. None of these patients were compliant with brace wearing. Of the 70 feet, 40 (57%) required surgical intervention. There were 30 (43%) feet with no clinical recurrence. In 5 of the bilateral cases only one of the feet had required corrective surgery. In the 29 patients who required surgical intervention we identified 52 procedures (37 extra-articular and 15 intra-articular). Compliance with the post correction abduction bracing protocol is crucial to avoid recurrence of a clubfoot deformity treated with the Ponseti method. Despite non-compliance however there is a significant proportion of patients who do not require any surgical intervention. We recommend initiating the Ponseti technique on all patients with clubfeet rather than being selective due to anticipated compliance issues with the family

Non-operative treatment methods of idiopathic clubfoot have become increasingly accepted worldwide as the initial standard of care. The Ponseti method has become particularly popular due to published short and long term success rates in North America. The purpose of the current study was to examine the early rate of relapse in a New Zealand population and analyze patient characteristics for factors predictive of relapse. Fifty-one consecutive babies with seventy-eight club-feet treated by the Ponseti technique were followed prospectively for a minimum of two years from the start of treatment. Recurrence, defined as the need for any operative intervention, was analyzed with respect to severity at presentation, timing of presentation, the number of casts needed to obtain correction, family history of clubfoot, ethnicity, and compliance with abduction bracing. Recurrence was subdivided into minor recurrences, defined as a tendon transfer or Achilles lengthening, and major recurrences, defined as a full posterior or posteromedial release. Twenty patients (39%) had a recurrence. Eleven patients (22%) had a major recurrence and nine patients (17%) had a minor recurrence. Only three of twenty-five patients (12%) who were compliant with bracing had a major recurrence. Twenty-five of fifty-one patients (49%) were compliant with bracing. The greatest risk factor for recurrence was non compliance with abduction bracing, with an odds ration of 5 (p = 0.009). Although not quite statistically significant (p = .07), ethnicity was also related to recurrence, with Polynesian patients being three times less likely than white Europeans to recur. No statistically significant relationships were found between recurrence and severity at presentation, timing of presentation, the number of casts needed to obtain correction, or family history of clubfoot. Compliance with abduction bracing is crucial to avoiding recurrence of clubfoot. The Polynesian club-foot seems more amenable to Ponseti technique and less likely to recur than the white European clubfoot. In those patients who are compliant, the Ponseti method is very effective at maintaining a correction, with minimal need for major surgery. However, even among the compliant patients, minor recurrences are common, and among the noncompliant patients, many major and minor recurrences should be expected

Purpose. The rate of club foot recurrence following Ponseti treatment has been reported in the literature as between 14 and 58%. Recurrence is defined as any child who has been treated and is in need of recasting, surgery or bracing. True recurrence is defined as presentation 6 months after last treatment and incomplete treatment is defined as presentation within 6 months of last treatment. Currently no local data exists to determine the cause of recurrence in this unit. The aim of this study is to review all recurrences to improve the outcome of club foot management. Methods. A retrospective audit of all club foot recurrences was performed at an academic hospital. The review included the location of initial treatment, initial treatment method and abduction brace compliance as factors contributing to the recurrence rate. Results. Thirty seven (48%) patients attending the club foot clinic were recurrences – 68% were true recurrences and 32% were defined as incomplete treatments. The mean age at presentation of club foot recurrence was 25 months (Range 6–84 months). Seventy percent of recurrences were referred from outside healthcare facilities – all patients had serial manipulation and casting. The overall complete compliance for casting was 74%. Eighty percent of patients had a Tendo Achilles tenotomy at a mean age of 10.5 months (range 2–66 months) after initial plastering (mean 12.5 plasters). Post tenotomy, 65% had abduction bracing for a mean duration of 4.5 months and 35% had no bracing. No patient continued bracing until the recommended age of four years. Conclusion. Despite the challenges of compliance to casting the overwhelming identified problem is compliance with abduction bracing. The challenge is to improve bracing protocol and ensure compliance in this critical part in the treatment of club foot

Instability is the most common reason for revision after total hip arthroplasty (THA). Since THA requires arthrotomy of the hip and replacement with a femoral head that is smaller than the normal hip, instability following THA is always a potential concern. Many factors contribute to the development of instability after THA including: restoration of normal anatomy, implant design, component position, surgical approach and technique, and numerous patient related factors. Recently, the role of spinal mobility and deformity has been shown to have a significant effect on risk of dislocation after THA. The long held guidelines for component positioning or so called “safe zone” described by Lewinnek have also been questioned since most dislocations have been shown to occur in patients whose components are positioned within this “safe” range. In the early post-operative period, dislocation can occur prior to capsular and soft tissue healing if the patient exceeds their peri-operative range of motion limits. Closed reduction and abduction bracing for 6 weeks may allow for soft tissue healing and stabilization of the hip. It is important to try and identify the mechanism of dislocation since this can affect the technique of closed reduction, how the patient is braced following reduction and what may need to be addressed at the time of revision if dislocation recurs. Closed reduction and bracing may be effective in patients who have a previously well-functioning, stable THA who suffer a traumatic dislocation after the peri-operative period. Despite successful closed reduction, recurrent dislocation occurs in many patients and can be secondary to inadequate soft tissue healing, patient noncompliance or problems related to component positioning. Patients who incur more than 2 dislocations should be considered for revision surgery. Prior to revision surgery, an appropriate radiographic evaluation of the hip should be performed to identify any potential mechanical/kinematic issues that need to be addressed at the time of revision. Typically this involves plain radiographs, including a cross table lateral of the involved hip to assess acetabular version, but may also involve cross-sectional imaging to assess femoral version. Patients with soft tissue pseudotumors frequently have significant soft tissue deficiencies that are not amenable to component repositioning alone and require use of constrained or dual mobility components. In general, “limited revisions” consisting of modular head and liner exchange with insertion of a lipped liner and larger, longer femoral head rarely correct the problem of recurrent instability, since component malposition that frequently contributes to the instability is not addressed. Similarly, insertion of a constrained liner in a malpositioned cup is associated with a high rate of implant failure and recurrent dislocation since impingement contributing to the instability is not addressed. In patients who fail closed management and have a history of recurrent instability, we have found the treatment paradigm described by Wera, et al. to be very helpful in the management of the unstable THA. Several studies have shown that tripolar type constrained liners appear to perform considerably better than locking ring type constrained liners. As a result, dual mobility implants are becoming more widely utilised in patients with abductor and other soft tissue deficiencies, hip instability of uncertain etiology and patients with increased risk factors for instability undergoing primary THA. Early results with dual mobility components have been shown to have a low rate of failure in high instability risk revision THAs. These devices do have several unique potential complications and their use should be limited to patients with significantly increased risk of dislocation and instability

Most centres in the United Kingdom adopt a selective screening programme for developmental dysplasia of the hip (DDH) based on repeated clinical examination and selective ultrasound examination. The Newborn Infant Physical Examination protocol implemented in 2008 recommends a first examination at birth and then a second and final examination at six to ten weeks of age. Due to concerns over an increase in late presentations we performed a retrospective review of our 15-year results to establish if late presentation increases treatment requirements. Of children presenting before six weeks of age, 84% were treated successfully with abduction bracing, whereas 86% of children presenting after ten months eventually required open reduction surgery. This equates to a 12-fold increase in relative risk of requiring open reduction following late presentation. Increasing age at presentation was associated with an increase in the number of surgical procedures, which are inevitably more extensive and complex, with a consequent increased in cost per patient. The implementation of an opportunistic examination at three to five months could help to reduce the unintended consequences of the Newborn Infant Physical Examination programme. . Cite this article: Bone Joint J 2013;95-B:846–50

Aim. The objective was to assess whether late presentation of DDH leads to an increase in treatment magnitude and cost. Method. This was a retrospective review of prospectively collected data from our hip instability clinic database. All patients presenting to our hip instability clinic that required any form of treatment for DDH between 1990 and 2005 were included. Children were grouped according to age at presentation and then treatment requirements were reviewed. Average costs were calculated based on procedures performed. Results. 84% of children presenting before 6 weeks were treated successfully with abduction bracing, versus none after the age of 10 months. The need for open reduction increased from 8% if presenting before 6 weeks to 86% for those over 10 months. This equates to a 12-fold increase in relative risk of requiring open reduction surgery. Increasing age at presentation was associated with an increase in the number of procedures required, increased magnitude of procedure and increased financial cost per patient. Conclusion. The loss of repeated screening for DDH will lead to an increase in late presentations. This work has demonstrated that increased age of presentation leads to a concomitant increase in open reduction and other operative procedures. Implementation of an additional opportunistic mandatory screening examination at 3–5 months could help to reduce the unintended effects of the new guidelines

Objective. The objective was to assess whether late presentation of DDH leads to an increase in treatment magnitude and cost. Methods. This was a retrospective review of prospectively collected data from our hip instability clinic database. All patients presenting to our hip instability clinic that required any form of treatment for DDH between 1990 and 2005 were included. Children were grouped according to age at presentation and then treatment requirements were reviewed. Average costs were calculated based on procedures performed. Results. 84% of children presenting before 6 weeks were treated successfully with abduction bracing, versus none after the age of 10 months. The need for open reduction increased from 8% if presenting before 6 weeks to 86% for those over 10 months. This equates to a 12-fold increase in relative risk of requiring open reduction surgery. Increasing age at presentation was associated with an increase in the number of procedures required, increased magnitude of procedure and increased financial cost per patient. Conclusions. The loss of repeated screening for DDH will lead to an increase in late presentations. This work has demonstrated that increased age of presentation leads to a concomitant increase in open reduction and other operative procedures. Implementation of an additional opportunistic mandatory screening examination at 3–5 months could help to reduce the unintended effects of the new guidelines

The management of hip instability in the non-ambulant paediatric cerebral palsy (CP) patient is complex. Subluxations and dislocations arise secondary to muscle imbalance caused by strong hip flexors and adductors overpowering weaker hip abductors and extensors. These conditions give rise to sitting problems and can cause debilitating pain making care difficult. Treatment methods include physiotherapy, abduction bracing, muscle releases and transfers, proximal femoral and pelvic osteotomies, proximal femoral excision +/- interpositional arthroplasty, arthrodesis and total hip arthroplasty (THA). THA in the adult CP patient is not uncommon, however dislocation has remained a concern. THA is rarely used in the paediatric patient and to our knowledge the use of a constrained liner, which should prevent dislocation, has never been described. We present the case of a non-ambulant paediatric CP patient with normal intelligence whom by the age 16 had been successfully managed with staged bilateral uncemented THAs using constrained liner technology

Introduction. Dislocation is one of the most common complications following total hip arthroplasty. The literature suggests a frequency of 1–3% for primary total hip replacement (THR) and 7–10% for revision procedures. No definitive treatment algorithm exists for their management, with some surgeons attempting to constrain hip motion with casting or bracing initially. The evidence for this practice is limited. The purpose of this study was to determine the current practice for managing THR dislocation within our unit, and to determine the effectiveness of abduction bracing. Method. A retrospective case-note analysis was performed on all patients admitted with a dislocated THR between 01/01/08 and 31/12/10. Patients were categorised into three groups: first time dislocators, recurrent dislocators, or dislocation occurring following revision surgery. The following data was collected; time from original surgery, closed or open reduction, surgical approach, prescription of abduction brace post-operatively, and the number of subsequent dislocations. Any patients who underwent open reduction were excluded from the study. Results. A total of 45 patients were included in the study. Of the first time dislocators, 75% treated with abduction brace re-dislocated, and 26% of patients treated without bracing re-dislocated. In the recurrent group 63% had been braced after their initial dislocation. Conclusion. Based on this study the benefit of abduction braces is limited and patient compliance tends to be poor. The cost of these appliances is significant (£450/£525) and patients typically have a prolonged hospital stay for ordering and application. Our unit has subsequently discontinued the use of such braces. Goals to reducing THR dislocation remain; meticulous preoperative planning and patient selection, accurate component positioning with intraoperative stability testing, good soft tissue repair, and early patient education

Aims

Perthes’ disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes’ disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes’ disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample?

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

Aims

Severe acetabular bone loss and pelvic discontinuity (PD) present particular challenges in revision total hip arthroplasty. To deal with such complex situations, cup-cage reconstruction has emerged as an option for treating this situation. We aimed to examine our success in using this technique for these anatomical problems.

Aims

Instability of the hip is the most common mode of failure after reconstruction with a proximal femoral arthroplasty (PFA) using an endoprosthesis after excision of a tumour. Small studies report improved stability with capsular repair of the hip and other techniques, but these have not been investigated in a large series of patients. The aim of this study was to evaluate variables associated with the patient and the operation that affect post-operative stability. We hypothesised an association between capsular repair and stability.