Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme over the last 19 years. The following shows our result after a recent change in our screening programme protocol. All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic.

However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatment. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS. No complications were noted.

While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced. Yet, the need for a major surgical intervention has been all but eliminated.

Universal neonatal screening of developmental dysplasia of the hip (DDH) remains controversial and a few centres have adapted this practice in the United Kingdom. Our institute has established a DDH screening programme for many years. The following shows our result after a recent hospital relocation and changes to the screening programme.

All infants born in Coventry are screened for DDH by a clinical examination and ultrasound scan (USS). 5,084 babies were born over a 12-months period. Normal examination and USS were detected in over 90% of the cases. Abnormality detected through either clinical examination or USS was referred to a special orthopaedic/USS clinic. However, in the majority of the cases, subsequent assessments were normal and only 23 babies required treatments. In these cases, the majority had not shown any signs of clinical abnormality. However, serial USS had shown persistent abnormality of at least Graf grade II or higher. The average time from birth to a treatment with a Pavlik Harness was 35 days and the average duration of a treatment was 48 days. Those with Graf III or higher at initial presentation, but spontaneous reduced without treatment were follow-up to one year. The acetabular index in these cases was normal. Apart from one case, all the babies were treated successfully. The unsuccessful cases had a Graf grade IV at the presentation and had shown no sign of improvement on sequential USS.

While the sensitivity of detecting DDH through clinical examination remains poor, USS has become an essential tool in our screening programme. Many initial abnormalities are secondary to hip immaturity and they tend to resolve. Those with clinical instability and persistent USS Graf grade II or higher should be treated with early Pavlik Harness. Early detection has led to better results than late diagnosis, and in addition to this, the overall number of operations required could be reduced.

Introduction: Despite worldwide vaccination programmes Polio is still endemic in some developing countries. Numerous new cases of polio are seen every year in India resulting in significant childhood deformity. The Rotary Club funds voluntary camps aimed at correcting deformities in children. I was part of the surgical team in Jan 2007 led by Mr. J. Clegg.

Clinical experience: Some 141 procedures were carried out in 3 days, 99 by SPR’s under senior supervision. The most frequent procedure was a supra-condylar femoral osteotomy, followed by hip and knee soft tissue releases. For more complex operations we assisted or observed. Some deformity corrections were for non-polio cases. Interesting cases in the OPD included skeletal dysplasias, rickets and congenital deformities.

Conclusion: At the time where MMC restricts overseas training opportunities, I believe this type of mini-fellowship provides valuable experience. Training programmes should have such opportunities available to all trainees.

Purpose of study: The UMEX frame was developed from the Joshi external fixator, being first used in the UK in 2004. It corrects deformity by gradual distraction and manipulation. We report the outcomes of a two centre combined experience of the UMEX frame for the treatment of complex congenital foot deformities.

Method: The frame was used in the management of 27 complex foot disorders, the majority of which were resistant club feet. All patients had at least 18 month follow up.

Results: Good deformity correction was achieved in all cases, with a plantigrade foot immediately post-treatment. However, minor degrees of relapse have been noted when the strict postoperative regimen was not followed.

Conclusions: The application of external fixators for the correction of foot deformities can be a complex procedure for the surgeon, and cumbersome for the patient. This frame is simple to apply and manage and allows multi-planar deformity correction in one stage. Our experience and patient outcome data suggest that this technique is a useful surgical option for the Paediatric Orthopaedic surgeon dealing with a relapsed club foot and other complex foot deformities.

Introduction: The UMEX system of external skeletal fixation has been widely used on the Indian subcontinent since its development by Dr. B.B. Joshi of Mumbai. The system employs a method of gradual distraction with manual correction of deformity. It has applications to both the upper and lower limbs, both in Orthopaedic and Traumatic conditions.

This paper aims to introduce the system to members of B.S.C.O.S. as an alternative method of correction of the relapsed clubfoot. It has a use in other Paediatric and Adult foot deformities.

The system is light and easy to apply, and unlike some other methods of external fixation is cheap and well tolerated by patients and their parents.

Results: This paper will describe the use of the device in the first 3 patients with club foot and with 2 others, one with deformity secondary to neurological abnormality, one patient with congenital abnormality of the forefoot.

The assessment of deformity in club foot is controversial and difficult to apply to many cases. The goal of treatment is a plantigrade and supple foot, that functions well in locomotion. To date, admittedly in a small number of cases, this has been achieved following relapse from earlier surgery.

Discussion: The management of relapsed club foot and other complex foot deformities is often far from easy, and results in a stiff foot, with some residual deformity evident after repeated surgery. The UMEX system, by combining distraction with gentle manual correction, has, in our hands, been effective in restoring shape and function to the foot without the need for invasive surgery.

Aim: Prospective study to evaluate the results and the technique of 63 proximal femoral osteotomies in 39 cerebral palsy patients performed with the new Fixclipª biological internal þxator system. Methods: Thirty nine cerebral palsy patients with dislocated or painful subluxing hips, who underwent upper femoral osteotomy from 2 different centres in the last 7 years were included in the study. Results: The average age of patients at operation was 12.7 years (range 3 Ð 60 years). All the patients were followed up until union. Some had removal of the implant. Postoperative splintage was normally used when soft tissue procedures were performed along with femoral osteotomy. Three patients needed revision surgery for readjustment of the device and 2 patients had superþcial infections. All osteotomies healed by 12–16 weeks apart from one. There was no malunions, or avascular necrosis. One patient had a non-union that united after revision surgery. Conclusion: The Fixclips system is modular and easily adjustable. The system lies off the bone with minimal disturbance to the periosteal blood supply. Compared to other implants, Fixclips are biologically and mechanically very effective with low complications and well suited in cerebral palsy patients where rigid þxation can cause extensive loss of bone mass. This is the þrst study reporting the use of ÔFixclipsñ system for upper femoral osteotomy.

Aims: Prospective study to evaluate the radiological outcome of developmental dysplasia of the hips at 1 year, which were ultrasonographically abnormal at birth. Methods: Routine ultrasound screening for neonatal hip instability has been carried out in Coventry since June 1989. Of the 8007 babies born in Coventry during 1997,1998 and early 1999, 534(6.6%) babies were found to have early ultrasonographic abnormality. Inclusion criteria for our study were an early abnormal ultrasound examination in babies with no other risk factors. Pavlik harness treatment was started for babies with persistent abnormality. Results: 212 babies were available for follow up at 1year with X-ray for measurement. Study criteria matched 230 new born hips in 115 babies with average radiographic follow-up of 52 weeks (range 48Ð60weeks). Acetabular angle and the femoral head epiphysis were measured from the pelvic X-ray. The results were statistically analyzed and the F-value was calculated. Ultrasonic abnormality was common in female babies (83%: 17%) compared to male babies. The results in the severely abnormal group following treatment with Pavlik Harness were found to be the same as the mildly abnormal group. Conclusions: We hereby conclude that treatment of the severely abnormal group with Pavlik Harness has resulted in no statistically signiþcant radiological abnormality in the acetabular angle and the growth of the femoral head epiphysis at 1-year follow up.

Aims: The new Fixclips are used with 0.8mm to 3.0mm diameter wires and screws to þx osteotomies and fractures. This study deals with the biomechanical properties of the þxclip system. Methods: The range of normally accepted screw tightness was established by using a torque screwdriver at surgery. The mechanical grip-strength over this torque range was measured using a Hounsþeld Tensometer in the laboratory. The þxation was simulated using Tufnol material and the effect of additional clips on the grip strength and the stability of the construct was assessed. Results: Pull out force depends on the wire size and varied linearly over the clinical range of screw torque (0.25 to 3Nm) with values from 50 N to 900 N. An additional clip increases the pull-out force upto 3000N and the adjusting the distance also affects the test results. The strength increased with the distance between the clips and a maximum was obtained at a distance of 4.5cms between the clips. Conclusions: The system is modular and is designed to lie slightly off the bone causing minimal damage to the underlying periosteum and hence less disturbance to blood supply. The system is cost effective, less time consuming and mechanically reliable and stable for the given clinical situations. It has signiþcant advantage over the existing methods of þxation especially in paediatric orthopaedic and trauma situations.

Aim: Many risk factors for DDH are well documented. This study was undertaken to investigate whether multiple pregnancy is a risk factor for developmental dysplasia of hips. Method: During a 10-year period from 1989 to 1998, 39826 newborn babies had their hips scanned. Of these, 1022 (2.6%) babies were non-singletons. Inclusion criteria for our study were all non-singletons, who had their hips scanned in the þrst week after birth. We analyzed the results of their hip scans and calculated the risk for developing DDH either alone or with other risk factor and other variables like the gender, mode of delivery, birthweight and the length of pregnancy. Results: Of the 1022 babies, 825 (80.7%) had their hips scanned in the þrst week. M: F: 49.6%: 50.4%. We had 397 sets of twins, 9 sets of triplets and 1 set of quadruplet. 78% of this group had a normal presentation. 21% (181) of these babies were breech. There was no family history associated with any of the multiple births. Ultrasound abnormality was seen in 30 hips (1.8%). 1 patient had Pavlik harness treatment for persistent ultrasound abnormality. No signiþcant correlation was seen in the gender or in the length of pregnancy. Conclusion: Though it is a general impression that the hips of the non-singletons are under high mechanical stress during pregnancy and would be expected to have a relatively high incidence of DDH, from our study it is evident that the risk is no greater than the normal singletons.

Aims: Prospective study to evaluate the radiological outcome of developmental dysplasia of the hips at 1 year in breech babies, whichwere ultrasonographically abnormal at birth. Methods: Routine ultrasound screening for neonatal hip instability has been carried out in Coventry since June 1989. Of the 16000 babies born in Coventry during 1995,1996,1997and1998, 759 (4.7%) were Breech born. Of these, 100(13%) babies had early ultrasonographic abnormality of the hips. Inclusion criteria for our study were an early abnormal ultrasound examination in breech babies with no other risk factors. Babies with family history of CDH were excluded. Pavlik harness treatment was started for babies with persistent abnormality. Results: Study criteria matched 56 new born hips in 46 breech babies with average radiographic follow-up of 52 weeks (range 48Ð60weeks). Acetabular angle and the femoral head epiphysis were measured from the pelvic X-ray. The results were statistically analyzed and the F-value was calculated. Ultrasonic abnormality was common in female babies (74%: 26%) compared to male babies. The results in the severely abnormal group following treatment with Pavlik Harness were found to be same as the mildly abnormal group. Conclusions: We hereby conclude that treatment of the severely abnormal group with Pavlik Harness has resulted in no statistically signiþcant radiological abnormality in the acetabular angle and the growth of the femoral head epiphysis at 1-year follow up in breech babies.

We have analysed the patterns of management of developmental dysplasia of the hip (DDH) in Coventry over a period of 20 years during which three different screening policies were used.

From 1976 to the end of 1985 we relied on clinical examination alone. The mean surgical cost for the treatment of DDH during this period was £5110 per 1000 live births. This was reduced to £3811 after the introduction of ultrasound for infants with known risk factors. Since June 1989 we have routinely scanned all infants at birth with a mean surgical cost of £468 per 1000 live births. This reduction in cost is a result of the earlier detection of DDH with fewer children requiring surgery. In those who do, fewer and less invasive procedures are needed. The overall rate of treatment has not increased and regular review of patients managed in a Pavlik harness has allowed us to avoid the complication of avascular necrosis.

When we add the cost of running the screening programme to the expense of treating the condition, the overall cost for the management of DDH is comparable for the different screening policies.

We have undertaken routine ultrasound screening for neonatal hip instability in Coventry since June 1989. Of the 14,050 babies scanned during the first three years, 847 (6%) had ultrasound abnormalities. A grading system, based on the percentage of femoral head coverage, is presented. The proportion of abnormal hips decreased gradually so that by nine weeks, 90% had normal ultrasound appearances. Abnormality was more common in babies with a family history of CDH and in breech presentations. All babies with clinically abnormal hips had an abnormal first ultrasound examination. Five babies not diagnosed by clinical examination and with no risk factors had abnormal ultrasound appearances and were subsequently found to have clinically abnormal hips. Routine ultrasound screening has detected cases which would otherwise have presented late.

Of 4,617 babies born in Coventry in 1986, a total of 448 (9.7%) had either clinical abnormality of the hip or at risk factors for CDH. All were examined by ultrasound, but only 17 required treatment (3.7 per 1,000); in five of these no clinical abnormality had been detected. An additional 81 babies had ultrasound abnormalities but did not require treatment, despite the fact that ultrasound at first showed major hip displacement in 17 of them. Three late cases of CDH have presented among the babies born in 1986, but not examined by ultrasound. This incidence of late CDH is unchanged compared with the previous nine years, although ultrasound had detected covert displacement in a number of hips.

Twenty-nine patients with thirty pseudarthroses after removal of infected total hip prostheses have been reviewed one to six years later. Six hips still had a discharging sinus. Complete removal of all cement was found to be essential for healing, and various points in the technique of its clearance have been made. In this respect radio-opaque cement was a great advantage, and lateral guttering of the femur was most effective. Compared with the situation before replacement considerable relief of pain was obtained in most patients but there was much less improvement in function.