Aim. The aim of this study is to assess the effectiveness of clinic based ultrasound screening by Orthopaedic surgeon for early diagnosis and treatment of developmental dysplasia of hip (DDH) in one stop clinic. Methods. This prospective study included 395 infants (185 male and 210 female) (5.2% of study population) who were referred for screening on the basis of abnormal findings or the presence of risk factors for DDH. Average age was 12.5 weeks (1 day to 15 months). All infants were assessed for risk factors of DDH. Clinical examinations were performed by the senior author followed by ultrasonography of both of the infant's hips, using the Graf's technique. Alpha and beta angles were calculated and hips were classified according to Graf's classification system. Results. Out of 790 hips examined 670 (84.8%) were labelled as normal. 120 (15.1%) hips in 84 patients were diagnosed as dysplastic or dislocated. Clinical examination only detected 39 patients out of 84, sensitivity of 46%. Average age of diagnosis was 12 weeks (3days-11 months). 79 patients were successfully treated with pavlic harness, 2 required traction and 3 were referred for surgical treatment. There were 14 cases of late diagnosis during one year period (> 4 months of age) (1.8/1000). Conclusion. Selective ultrasound screening is effective in early diagnosis of DDH and significantly reduces the duration of non operative treatment as well as the need for surgical intervention but does not completely eliminate late diagnosis of DDH. We find the concept of one stop DDH clinic highly effective and recommend that ultrasound training should be a part of orthopaedic curriculum

Purpose. There are concerns of soft-tissue reactions such as metal hypersensitivity or pseudotumors for metal-on-metal (MoM) bearings in hip arthroplasty, however, such reactions around ceramic or polyethylene bearings are incompletely understood. The present study was conducted to examine the capabilities of ultrasound screening and to compare the prevalence of periarticular soft-tissue lesions among various types of bearings. Methods. Ultrasound examinations were conducted in 163 hips (153 patients) with arthroplasty after mean a follow-up of 8.1 years (range, 1–22 years). This included 39 MoM hip resurfacings (M-HR) including 30 Birmingham hip resurfacings (BHR) and 9 ADEPT resurfacings; 36 MoM total hip arthroplasties (M-THA) with a large femoral head including 26 BHR and 10 ADEPT bearings; 21 ceramic-on-ceramic THAs (C-THA) of Biolox forte alumina bearings; 24 THAs with a conventional polyethylene liner (cPE-THA) including 19 Lubeck and 5 Omnifit systems; and 43 THAs with a highly cross-linked polyethylene liner (hxPE-THA) including 28 Crossfire and 15 Longevity liners. All procedures were performed in the lateral position through the posterior approach without trochanteric osteotomy. The M-HR group had a significantly higher frequency of male patients than the C-THA, cPE-THA, and hxPE-THA groups, and the patients in the M-HR group were younger than those in the other four groups. Ultrasound images were acquired as a still picture and in video format as the hip moved in flexion and rotation, and 4 qualitative classifications for periarticular soft-tissue reactions were determined as normal pattern, joint-expansion pattern (marked hypoechoic space between the anterior capsule and the anterior surface of the femoral component), cystic pattern (irregularly shaped hypoechoic lesions), and mass pattern (a large mass extending anterior to the femoral component). Magnetic resonance imaging (MRI) was subsequently performed in 45 hips with high-frequency encoding bandwidths. For the reliability of ultrasound screening, positive predictive value, negative predictive value, and the accuracy of the presence of abnormal patterns on ultrasound were calculated using the abnormal lesions on MRI as a reference. Results. Among the 45 hips that underwent MRI, periarticular abnormal lesions were detected in 26 hips (58%). Using MRI findings as reference, positive predictive value, negative predictive value, and the accuracy of ultrasound examination for the detection of soft-tissue lesions were 83%, 71%, and 78%, respectively. Abnormal ultrasound lesions with joint expansion, cystic, or mass patterns were most frequently observed in the cPE-THA group (50%), followed by the M-THA (25%), hxPE-THA (23%), M-HR (18%), and C-THA groups (14%). Compared to the hxPE-THA group, the frequency of abnormal patterns did not differ significantly in the two MoM groups. A mass pattern was detected in 3 hips of the M-THA group and 1 hip of the C-THA group (Figure 1). Abnormal ultrasound lesions were significantly associated with the presence of symptoms. Conclusion: Various soft-tissue reactions could be observed other than those for MoM bearings, and pseudotumors may not be a specific feature of MoM bearings. Ultrasound examination may be a suitable screening tool for further large prospective investigations of soft-tissue reactions around various types of bearings

The prevalence of pseudotumours in patients with large-head metal-on-metal (MOM) THA has been the subject of implant recalls and warnings from various regulatory agencies. To date, there is no consensus on whether ultrasound or MRI is superior for the detection and following the progression of pseudotumours. Ultrasound is relatively cheap but can be operator dependent. MARS MRI has the advantage of excellent visibility of the soft tissue. However, MRI comes at a marked increase cost and takes about twice as long to perform.

At our institution, we prospectively compared ultrasound to MRI for pseudotumour detection in an asymptomatic cohort of patients with MOM THAs.

We enrolled 40 patients with large-head MOM THAs in the study. The mean age was 54 years (range, 34–76 years). The mean time from surgery was 54 months (range, 40–81 months). There were 28 men and 12 women. All patients underwent ultrasound and MRI using slice encoding for metal artifact correction. The gold standard was defined as follows: if both ultrasound and MRI agreed, this was interpreted as concordant and the result was considered accurate.

Ultrasound and MRI agreed in 37 of 40 patients (93%). The prevalence of pseudotumours was 31% (12 of 39) in our cohort. Twenty-three of 39 patients (59%) had completely normal tests and four (10%) had simple fluid collections. Ultrasound had a sensitivity of 100% and specificity of 96% while MRI had a sensitivity of 92% and specificity of 100%.

Conclusions: A negative ultrasound rules out pseudotumour in asymptomatic patients as this test is 100% sensitive. Given its lower cost, we recommend ultrasound as the initial screening tool for pseudotumours.

More recently, Kwon et al have compared ultrasound to MARS MRI for following the progression of pseudotumours. They found a strong agreement between the 2 modalities for assessing change in size and consistency of pseudotumours.

The prevalence of pseudotumours in patients with large-head metal-on-metal (MOM) THA has been the subject of implant recalls and warnings from various regulatory agencies. To date, there is no consensus on whether ultrasound or MRI is superior for the detection of pseudotumours. Ultrasound is relatively cheap but can be operator dependent. MARS MRI has the advantage of excellent visibility of the soft tissue. However MRI comes at a marked increase cost and takes about twice as long to perform.

At our institution we prospectively compared ultrasound to MRI for pseudotumour detection in an asymptomatic cohort of patients with MOM THAs.

Aims. We investigated the local epidemiology of Developmental Dysplasia of the Hip (DDH), in order to define incidence, identify risk factors, and refine our policy on selective ultrasound screening. Methods. Data were recorded prospectively on all live births in the Exeter area from January 1998 to December 2008. We compared those treated for DDH with all other children. Crude odds ratios (OR) were calculated to identify potential risk factors. Logistic regression was then used to control for interactions between variables. Results. There were 182 children with DDH (245 hips) and 37,051 without. The incidence was thus 4.9 per 1000 live births. Female sex (adjusted OR 7.2, 95% CI 4.6-11.2), breech presentation (adjusted OR 24.3, 13.1-44.9), positive family history (adjusted OR 15.9, 11.0-22.9) and first or second pregnancy (adjusted OR 1.8, 1.5-2.3) were confirmed as risk factors (p<0.001). In addition, there was an increased risk with vaginal delivery (adjusted OR 2.7, 1.6-4.5, p<0.001) and postmaturity (OR 1.7, 1.2-2.4, p<0.002). Conclusions. One in 200 children born in our area requires treatment for DDH. Using both established and novel risk factors, we can potentially calculate an individual child's risk. Our work may contribute to the debate about selective versus universal ultrasound screening

Developmental dysplasia of the hip (DDH) is the most common paediatric hip condition and is a major cause of hip replacement or osteoarthritis in young adults. Due to potential impact on quality of life, every child is checked at birth for unstable hips. Should instability be detected, or the infant has other DDH risk factors, they are referred for an ultrasound exam and orthopaedic surgeon consultation. Since the implementation of a DDH screening program at our institution, the Radiology Department has seen a dramatic increase in hip ultrasounds performed. While helping prevent the complications of missed DDH diagnoses, this program has placed strain on radiology resources, and often families must attend multiple appointments before receiving a diagnosis and beginning treatment. To mitigate this, we have implemented a pilot point-of-care DDH clinic, where an ultrasound technician performs hip ultrasound exams using a portable ultrasound in the orthopaedic clinic in conjunction with surgeon consultation. The aim of this clinic is to enable diagnosis and treatment in one appointment, reduce referral-to-treatment delays, wait times, and decrease costs and travel time for families while also alleviating strain on radiology resources. A point-of-care DDH test clinic was implemented in the Orthopaedic Department at our institution. Patients referred with suspected/confirmed DDH attended a single orthopaedic clinic appointment. An ultrasound technician was present to perform scans in conjunction with the orthopaedic surgeon's clinical assessment. Surveys were distributed at the end of the appointment to collect feedback on the family's satisfaction with the program, as well as other pertinent demographic information (i.e. occupation, geographic location, travel time to hospital). To date, 40 patients have attended the pilot clinic. Families spent an average 61.3 minutes (range 15–420 minutes) traveling to the hospital for an appointment (122.6 minutes round-trip). This program reduced the number of hospital visits for DDH screening from three (initial consultation, radiology, follow-up) to one per patient, saving an average 245.2 minutes of travel time to/from the hospital per family. Appointment time averaged 35.9 minutes and families rated their satisfaction with appointment length an average of 9.6/10 (35/40 families rated satisfaction 10/10, 1 = very unsatisfied, 10 = very satisfied). Additionally, 33/40 families were also asked to rate their satisfaction with check-in/check-out processes (average 9.4/10), ultrasound screening (average 9.9/10), and time with specialist (average 9.9/10). Satisfaction scores did not differ based on variables such as survey taker's gender, occupation, or geographic location. The pilot point-of-care ultrasound DDH clinic has considerably reduced the number of clinic visits and travel time for families, reduced aggregate clinic wait times, and has resulted in high family satisfaction. This specialized clinic may have potential to free up hospital staff time and resources, possibly decreasing wait times in other clinical areas, ultimately improving quality of care for patients and families across our institution

Early detection of Developmental Dysplasia of the Hip (DDH), and treatment, may prevent the need for surgical correction following late presentation. Neonatal examination, and ultrasound screening of at risk groups, does not detect all cases. Most neonates treated in the Intensive Care Unit (NICU) have abdominal radiographs performed during their stay. These include the hips but DDH is not routinely looked for. 50 neonatal abdominal films (five from patients who subsequently were found to have DDH, 45 from patients without this condition) were randomly shown to three paediatric orthopaedic surgeons and three paediatric radiologists on two separate occasions. Each was asked whether they would refer the patient for further investigation. An overall sensitivity of 25.5% (Range 0–60%) and specificity of 93.2% (Range 87–97%) was found with a positive predictive value (PPV) of 14.0% (Range 0–37%) and negative predictive value (NPV)of 96.3% (Range 95–98%). Although the low sensitivity and PPV make interpretation of these films a poor way to diagnose DDH, the high specificity and NPV suggest that they may be used as a prompt to further investigation. Therefore, we propose that DDH should be looked for on these films and, where there is radiological suspicion, ultrasound examination should be advised

The purposes of this study were to investigate whether twins and multiple births have a higher incidence of Developmental Dysplasia of the Hip (DDH), and whether universal ultrasound scanning would be beneficial in this population. Methods. Records of all twin and multiple births between 1st January 2004 and 31st December 2008 at Addenbrooke's Hospital were obtained. Information regarding sex, gestation, birth weight, DDH risk factors, results of the neonatal hip examination and of any ultrasound scans were analysed. The incidence of DDH in singletons born during the same period was calculated from birth records and the DDH database. Results. Of the 990 twin and multiple births, 267 had ultrasound scans. Of those scanned, over 92% had a normal (bilateral Graf I) scan initially. Within the study cohort there was one case of DDH diagnosed on ultrasound and successfully treated with Pavlik harness. There were two cases of late presenting DDH, one at 8 months and one at 14 months old. Both had no risk factors, a normal neonatal examination and consequently had not had an ultrasound scan. Conclusion. In our study, twins did not have a significantly higher incidence of DDH compared to singletons. However, ultrasound screening of twins would have detected the two late presenting cases of DDH earlier. It remains to be seen whether universal scanning would be cost-effective

Introduction. This is a retrospective review of the incidence of deep venous thrombosis (DVT) in 679 consecutive unilateral primary hip arthroplasty procedures performed between January 2007 and December 2010 managed with no anticoagulants. Mean age at operation was 58 years. Mean BMI was 26. The prophylaxis regimen included hypotensive epidural anesthesia, compression stockings, intermittent calf compression, early mobilization and an antiplatelet agent. Methods. 562 hybrid hip resurfacing procedures and 117 uncemented THRs, all performed through a posterior incision were included. Doppler ultrasound screening for DVT was performed in all patients between the fourth and sixth post-operative days. Patients were reviewed clinicoradiologically 6 to 10 weeks after operation and with a postal questionnaire at the end of 12 weeks to detect symptomatic VTE incidence following discharge. 14 patients with pre-existent VTE, coagulation disorders or cardiac problems requiring anticoagulant usage were excluded. Results. There were no symptomatic DVTs. Ten cases (1.5%) of asymptomatic below-knee DVT and 1 above-knee asymptomatic DVT (0.15%) were detected on USG. One patient had non-fatal pulmonary embolism but no evidence of lower limb DVT on repeated USG examinations. On investigation he was found to have Prothrombin 20210A mutation. The incidence of DVT was 1.6% (9 of 562) in the resurfacing group and 1.7% (2 of 117) in the THA group, an overall incidence of 1.6% (11/679) in the whole group. Fourteen patients (2.1%) needed a blood transfusion including 9 resurfacings (1.6%) and 5 THAs (4.3%). Discussion and Conclusion. This combination regimen which offers the prospect of low incidence of venous thromboembolism, without subjecting patients to the higher risks of bleeding associated with anticoagulant usage

Dynamic 2D sonography of the infant hip is a commonly used clinical procedure for developmental dysplasia of the hip (DDH) screening. It however has been found to be unreliable with some studies reporting associated misdiagnosis rates of up to 29%. In a recent systematic review, Charlton et al. examined dynamic ultrasound (US) screening for hip instability in the first six weeks after birth and found current best practices for such early screening techniques to be divergent between international institutions in terms of clinical scanning protocols. Such protocols include: the appropriate scanning plane and US probe position (e.g. coronal, transverse, lateral, anterior), DDH diagnostic metrics (e.g. femoral head coverage, alpha angle), appropriate patient age when scanning, and follow up procedures. To improve reliability of diagnosis and to help in standardizing diagnosis across different raters and health-centers, we propose an automated method for dynamically assessing hip instability using 3D US. 38 infant hips from 19 patients were scanned with B-mode 3D US by a paediatric orthopaedic surgeon and two technologists from the radiology department at a paediatric tertiary care centre. To quantify hip assessment, we proposed the use of femoral head coverage variability (ΔFHC3D) within 3D US volumes collected during a sequence of US scans (one at rest, and another with posterior stress applied to the joint as maneuvered during a dynamic assessment). We used phase symmetry image features to localize the ilium's vertical cortex and a random forest classifier to identify the location of the femoral head. The proposed ΔFHC3D provided good repeatability with an average test-retest ICC measure of 0.70 (95% confidence interval: 0.35 to 0.87, F(21,21) = 7.738, p<.001). The mean difference of ΔFHC3D measurements was 0.61% with a SD of 4.05%. Since the observed changes in ΔFHC3D start near 0% and range up to about 18% from stable to mildly unstable hips in this cohort, the mean difference and standard deviation of ΔFHC3D measurements observed suggest that the proposed metric and technique likely have sufficient resolution and repeatability to quantify differences in hip laxity. The long-term significance of this approach to evaluating dynamic assessments may lie in increasing early diagnostic accuracy in order to prevent dysplasia remaining undetected prior to manifesting itself in early adulthood joint disease

Developmental dysplasia of the hip (DDH) is the commonest musculoskeletal condition diagnosed in neonates. Two previous studies showed no statistical advantage with the addition of ultrasound to clinical screening. In the UK, the Standing Medical Advisory Committee (SMAC) (1969) recommended clinical examination at birth and at 6 weeks. The Newborn Infant Physical Examination (NIPE) (2008) guidelines in addition advised ultrasound scanning for clinically unstable hips or for those with risk factors (breech presentation or family history). We compared SMAC and NIPE in the two main hospitals of the East Lancashire Hospitals NHS Trust: Burnley General Hospital (BGH) and the Royal Blackburn Hospital (RBH), respectively. Our outcome measure was the number of irreducible hip dislocations over a two year period (2007–2008). The records of the lead Paediatric Orthopaedic Surgeon were used to identify all cases of irreducible hip dislocations born in 2007 and 2008. Maternity records provided information on birth statistics. Syndromal cases were excluded from further analysis. BGH had 5382 live births and 7 irreducible hip dislocations (incidence 1.3/1000 births). 4/7 met SMAC recommendations and 6/7 met NIPE guidelines. 2/7 had equivocal clinical examinations at birth. 13 children were referred to the clinic with unstable hips (2.42/1000 births). RBH had 7899 total births and 3 irreducible hip dislocations (incidence 0.38/1000 births). 2/3 met NIPE guidance and 1/3 met SMAC recommendations. 33 were referred to the clinic with unstable hips (4.18/1000 births). The difference in the numbers of irreducible hips did not reach statistical significance (p=0.12). This study found no statistically significant advantage with the addition of selective ‘at risk’ ultrasound screening to clinical screening alone. Confounding factors in this study included the age of referral of cases to clinic and the numbers of cases referred as primary instability. These findings are in keeping with two previous studies in Norway

Although physical and ultrasound (US)-based screening for congenital deformities of the hip (developmental dysplasia of the hip, or DDH) is routinely performed in most countries, one of the most commonly performed manoeuvres done under ultrasound observation - dynamic assessment - has been shown to be relatively unreliable and is associated with significant misdiagnosis rates, on the order of 29%. Our overall research objective is to develop a quantitative method of assessing hip instability, which we hope will standardise diagnosis across different raters and health-centres, and may perhaps improve reliability of diagnosis. To quantify dynamic assessment, we propose to use the variability in femoral head coverage (FHC) measurements within multiple US scans collected during a dynamic assessment. In every US scan, we use our recently-developed automatic FHC measuring tool which leverages phase symmetry features to approximate vertical cortex of ilium and a random forest classifier to identify approximate location of the femoral head. Having estimated FHC in each scan, we estimate the change in FHC across all the US scans during a dynamic assessment and compare this change with variability of FHC found in previous studies. Our findings - in a dynamic assessment on an infant done by an orthopaedic surgeon, the femoral centre moved by up to 19% of its diameter during distraction, from 55% FHC to 74% FHC. This variability is similar to the variability of FHC in static US scans reported in previous studies, so the variability in FHC readings we found are not indicative of any subluxation or dislocation of the infant's femoral head. Our clinician's qualitative assessment concluded the hip to be normal and not indicative of instability. This suggests that our technique likely has sufficient resolution and repeatability to quantify differences in laxity between stable and unstable hips, although this presumption will have to be confirmed in a subsequent study with additional subjects. The long-term significance of this approach to evaluating dynamic assessments may lie in increasing early diagnostic sensitivity in order to prevent dysplasia remaining undetected prior to manifesting itself in early adulthood joint disease

Introduction. Metal on metal hip resurfacing (MoM HR) is attractive for young active patients. Patients with osteonecrosis of the femoral head (ONFH) are relatively young. HR can be an option of treatment, however, long-term stability of the femoral component is a concern because of the necrotic lesion in the femoral head. There is also a concern of ARMD for MoM implants. The purpose of this study is review a 10 year outcome of a consecutive patients with ONFH who underwent MoM HR. Methods. The subjects of this study were 30 hips of 26 patients with ONFH who underwent HR between 1998 and 2004. There were 21 hips of 18 males and 9 hips of 8 females. The average age at operation was 40 years (range, 20–63 years). 19 ONFHs were induced by steroid and 11 ONFHs were alcohol related. According to the Japanese Investigation Committee classification, there were 8 hips with Type C1 and 22 hips with Type C2. There were 16 hips in stage 3A, 7 hips in Stage 3B, and 7 hips in Stage 4. Operation was performed through a posterior approach. A fragile necrotic bone was curettage thoroughly and the defect was filled with cement. Results. The average Harris hip score improved from 61 preoperatively to 97 at the final follow-up. The average radiographic inclination of the cup was 43 degrees (34–54 degrees) and the average anteversion was 12 degrees (4– 22 degrees). There was no dislocation. One hip had a late hematogenous infection at 9 years after surgery. Two hips of two patients with alcoholic ONFH had a mechanical loosening of the femoral component at 10 year and 13 years after surgery. The survivorship with revision for aseptic loosening as the endpoint was 96% at 10 years. There was no ARMD by ultrasound echo screening. There was no stress shielding of the femur at the final radiographic examination. Conclusion. Our over 10 year results of MoM HR for ONFH showed a high Harris hip score without dislocation. Although this series included the initial learning curve of the HR procedure, the survivorship with revision for aseptic loosening as the endpoint at 10 years was high. There was no ARMD by ultrasound echogram. MoM HR is a good option of treatment for ONFH