We present a review of our Specialist Physiotherapy clinic for normal physiological variations of the lower limb (SPNV) clinics, demonstrating them to be clinically effective and cost effective. Children with normal variation of rotational profile and limb angulation present much anxiety to parents and primary care. Providing consultation: to eliminate significant pathology and reassure families, is an important service that a Paediatric Orthopaedic department provides. In our tertiary referral department we have a Specialist Physiotherapy led clinics into which primary care practitioners refer children with whom there are concerns about lower limb development variation. The (SPNV) Clinic was first set up by a Consultant and Senior Physiotherapist in 1999. The aim of the clinic was to reduce the waiting times for incoming referrals but ensuring they are seen in an appropriate environment by an experienced health care professional. Clinics are run by Senior Specialist Physiotherapists, alongside Consultant clinics who are available for advice and direction. This provides security for the physios, the Trust and the patient. Over 15 years there have been more than 4000 patient visits to this clinic. Over 80% were new patient visits. 70% of these visits were discharged in one or two reviews. 97.4% of new referrals were discharged without subsequent review by an orthopaedic surgeon. The most common conditions reviewed were Genu valgum (25%), Genu Varum (16%), intoeing (17%) and flexible flat feet (11%). The clinic has proven to be cost effective as well in drawing in up to £500,000 revenue into the trust in a single year. The department has been approached by other trusts to assist in the implementation of similar clinics. We present this review of the patients, as a template for supporting the work of Paediatric Orthopaedic Departments. This service has facilitated the streamlining of our Consultant Paediatric Orthopaedic clinics

Aims. A clicky hip is a common referral for clinical and sonographic screening for developmental dysplasia of the hip (DDH). There is controversy regarding whether it represents a true risk factor for pathological DDH. Therefore a 20-year prospective, longitudinal, observational study was undertaken to assess the relationship between the presence of a neonatal clicky hip and pathological DDH. Patients and Methods. A total of 362 infants from 1997 to 2016 were referred with clicky hips to our ‘one-stop’ paediatric hip screening clinic. Hips were assessed clinically for instability and by ultrasound imaging using a simplified Graf/Harcke classification. Dislocated or dislocatable hips were classified as Graf Type IV hips. Results. The mean age at presentation was 13.8 weeks (12.8 to 14.7). In all 351 out of 362 children (97.0%) had Graf Type I hips (normal) that required no treatment. Nine children (2.5%) had Graf Type II hips but all resolved to Graf Type I hips on follow-up scans. One child (0.3%) had Graf Type III hip dysplasia and one child (0.3%) had an irreducible hip dislocation. The two pathological hips were associated with unilateral limited hip abduction. Mean referrals increased from 12.9 to 23.3 each year (p = 0.002) from the first decade of the study to the second, driven by increasing primary care referrals (5.5 versus 16.7 per year, p < 0.001). Conclusion. Most clicky hips required no treatment other than reassurance to parents. Clicky hips with a normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However, an abnormal hip examination including unilateral limited hip abduction should prompt urgent further investigations. Cite this article: Bone Joint J 2017;99-B:1533–6

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Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population.

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

Purpose. This 20-year prospective longitudinal observational study aims to determine the incidence of pathological developmental dysplasia of the hip (DDH) in children referred with clicky hips and define the risk posed to inform neonatal hip screening programmes including the role of ultrasound. Method. 355 children from 1997 to 2016 were referred with clicky hips to our “one stop” paediatric hip clinic under the local neonatal hip screening programme. Hips were assessed clinically for instability and by ultrasound using a simplified Graf classification. Dislocated or dislocatable hips were classed as Graf type IV. Results. The mean age at presentation was 13.9 (1–56) weeks. 343 out of 355 (96.6%) were Graf type I which required no treatment. 9 (2.5%) were Graf type II but all converted to Graf type I on follow up scans. 2 (0.6%) had Graf type III dysplasia and 1 (0.3%) had irreducible dislocation but all three were associated with limited hip abduction or other hip pathology. Referrals increased from 12.9 to 22.6 per year (p=0.002) from first decade of the study to the second, driven by rising primary care referrals (5.5 vs. 16.5 per year p=0.00002). Conclusion. The study provided robust evidence that overwhelming majority of clicky hips required no treatment other than reassurance to parents. Clicky hips with normal hip examination should be considered a variant of normal childhood and not a risk factor for DDH. However clicky hips with limited hip abduction may represent a separate clinical entity at risk of hip pathology and therefore warrant further investigations

The aim was to examine the descriptive epidemiology of Slipped Capital Femoral Epiphysis, with respect to geography and time. We extracted all children with a diagnosis of Slipped Capital Femoral Epiphysis from the Clinical Practice Research Database between 1990 and 2014 (24 years). CPRD is the world's largest database of primary care, which encompasses 8% of the UK population. CPRD was linked to Hospital Episode Statistics, and a validation algorithm applied to maximise sensitivity and specificity of the cases finding methodology. Poisson confidence intervals were calculated, and poison regression used. 596 cases of SCFE were identified. The internal validation algorithm supported a SCFE diagnosis in 88% cases. The age and sex distribution of cases mirrored that in the literature, offering external validity to the cases identified. There was no significant change in the incidence of SCFE over the 24-year study period, with the overall incidence being 4.8 cases per 100,00 0–16 year olds. There was no significant geographic variation in SCFE within the UK. There was a positive association with rising socioeconomic deprivation (p<0.01). There was no seasonal variation in presentation. This study found no evidence to support the common belief that SCFE incidence is increasing, and for the first time demonstrated an association with socioeconomic deprivation. The results are important for considering the feasibility of intervention studies, and offer insights into the disease aetiology

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To monitor the performance of services for developmental dysplasia of the hip (DDH) in Northern Ireland and identify potential improvements to enhance quality of service and plan for the future.

A study to assess the clinical importance of asymmetric thigh creases as the sole clinical sign in the diagnosis of developmental dysplasia of the hip. METHOD. All consultant clinic letters have been saved on a hospital hard drive since 1999. This drive was searched for the terms “thigh crease” and “skin crease”. Irrelevant letters and referral letters describing factors that would indicate screening in our unit were excluded leaving those with the sole referral complaint of asymmetric thigh creases (ATC). We also reviewed the original referrals of developmental dysplasia of the hip (DDH) patients managed by open or closed reduction. These patients were identified through operative coding. All available hard copy notes were reviewed and patients with neuromuscular conditions or longitudinal deficiency were excluded. Results were inputted into an Excel spreadsheet and analysed by a statistician at the University of Sheffield assuming a background population incidence for DDH of 1 in 1000. RESULTS. 399 computer files containing the search terms were identified. Many contained whole clinics of patient letters. After exclusions we identified 229 patients with the sole referral complaint of ATC. Three of the 229 patients had DDH, which was not statistically significant (p=0.107). The majority of the normal patients had radiological investigations. Hard copy notes were available and relevant for 130 of the 289 operatively managed patients, of whom one was initially referred with the sole complaint of ATC. Orthopaedic specialist examination demonstrated all four patients initially referred with only ATC had decreased abduction and shortening. CONCLUSION. We suggest if the primary health care professional is not confident to exclude DDH in the patient with ATC there is justification for referral, but in the absence of other clinical features or risk factors in the orthopaedic consultation there is no need for further investigation or follow up

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The aim of this study was to establish the incidence of developmental dysplasia of the hip (DDH) diagnosed after one-year of age in England, stratified by age, gender, year, and region of diagnosis.

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The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH).

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Despite the presence of screening programmes, infants continue to present with late developmental dysplasia of the hip (DDH), the impact of which is significant. The aim of this study was to assess infants with late presenting dislocation of the hip despite universal clinical neonatal and selective ultrasound screening.

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Although atlantoaxial rotatory fixation (AARF) is a common cause of torticollis in children, the diagnosis may be delayed. The condition is characterised by a lack of rotation at the atlantoaxial joint which becomes fixed in a rotated and subluxed position. The management of children with a delayed presentation of this condition is controversial. This is a retrospective study of a group of such children.

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

Perthes’ disease is an osteonecrosis of the juvenile hip, the aetiology of which is unknown. A number of comorbid associations have been suggested that may offer insights into aetiology, yet the strength and validity of these are unclear. This study explored such associations through a case control study using the United Kingdom General Practice Research database. Associations investigated were those previously suggested within the literature. A total of 619 cases of Perthes’ disease were included, as were 2544 controls. The risk of Perthes’ disease was significantly increased with the presence of congenital anomalies of the genitourinary and inguinal region, such as hypospadias (odds ratio (OR) 4.04 (95% confidence interval (CI) 1.41 to 11.58)), undescended testis (OR 1.83 (95% CI 1.12 to 3.00)) and inguinal herniae (OR 1.79 (95% CI 1.02 to 3.16)). Attention deficit hyperactivity disorder was not associated with Perthes’ disease (OR 1.01 (95% CI 0.48 to 2.12)), although a generalised behavioural disorder was (OR 1.55 (95% CI 1.10 to 2.17)). Asthma significantly increased the risk of Perthes’ disease (OR 1.44 (95% CI 1.17 to 1.76)), which remained after adjusting for oral/parenteral steroid use.

Perthes’ disease has a significant association with congenital genitourinary and inguinal anomalies, suggesting that intra-uterine factors may be critical to causation. Other comorbid associations may offer insight to support or refute theories of pathogenesis.