Aims

High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics.

Purpose

To determine (i) the relationship between osteonecrosis and hip function, physical function and quality of life in adolescents and young adults treated for DDH; and (ii) how affected children change over 10 years.

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 of the study

To determine the consistency with which specialist orthopaedic surgeons rate the importance of criteria for the diagnosis of DDH which had previously been generated in a BSCOS and EPOS multi national study.

Purpose

To determine the effect of the femoral head ossific nucleus on the development of avascular necrosis (AVN) after reduction of a dislocated hip.

We included consecutive patients treated for a dislocated hip secondary to DDH with either closed or open reduction under the age of 30 months (mean, 9.6□4.8) in this retrospective cohort study. 85 patients or 100 hips were included. Radiographs were analysed for the presence of the ossific nucleus at the time of hip reduction, and for the presence of AVN at 9.2□3.4 years after hip reduction by 3 blinded assessors. There was no significant effect of the femoral head ossific nucleus on the development of osteonecrosis, with 16/40 (40%) cases of osteonecrosis in infants with an ossific nucleus absent compared with 18/60 (30%) in the group with an ossific nucleus (adjusted relative risk = 0.83; 95% CI = 0.38 to 1.83; p=0.65). When only radiographic changes of grade II or worse were considered osteonecrosis, the association remained statistically insignificant (adjusted relative risk = 0.84; 95% CI = 0.35 to 2.00; p=0.69).

Purpose

To determine the impact of sonographic information on surgeons' diagnostic thinking and decision-making in the management of infants with clinically suspicious hip dysplasia.

Four experienced consultant surgeons examined 66 hips referred for possible hip dysplasia and reported for each hip (i) the confidence level (visual analogue scale 0-100) about the diagnosis of this hip, and (ii) how they would manage the hip. Each infant was referred to ultrasound and the same surgeon repeated the rating with the sonographic information available. We determined the efficiency in diagnostic thinking and calculated the mean gain in diagnostic confidence that was provided by the sonographic information. We also determined the therapeutic efficacy, ie the impact of ultrasound information on surgeons’ management plans.

The ultrasound led to a change in diagnosis in 34/66 (52%) hips. However, the management plan only changed in 21/66 (32%) hips. The mean gain in reported diagnostic confidence was 19.37 (95% CI = 17.27, 21.47). If the treatment plan did not change, there still was a gain in diagnostic confidence but this gain was small with a mean value of 8 (95% CI = 5.29, 10.70). However, if the ultrasound led to a change of the treatment plan, the mean gain in diagnostic confidence was much higher with 46 (95% CI = 30.53, 60.79). The difference was -37.67 (P < 0.0001). Ultrasound was most useful (mean gain >30) in hips demonstrating limited abduction or a positive Galeazzi sign.

Purpose: To determine the effect of the ossific nucleus on avascular necrosis (AVN) of the hip in the treatment of hip dislocation.

Methods: A systematic review was performed in MED-LINE, EMBASE, DARE, and Cochrane Library. Two independent reviewers evaluated all articles. Interrater agreement was determined by the kappa statistic. Quality of evidence was evaluated by the GRADE statement. A meta-analysis was performed on the main outcome, AVN 2 years after reduction.

Results: 6 observational studies met the inclusion criteria. Inconsistency was found in that half of the studies reported a protective effect of the ossific nucleus, whereas half of the studies did not. A meta-analysis of all studies (415 patients) showed no statistical significant effect of the ossific nucleus on the development of AVN, with 42 (17%) cases of AVN in infants with the ossific nucleus present at reduction compared with 47 (28%) in the group without a ossific nucleus (RR 0.60, 95% CI 0.28 to 1.27). If only radiographic changes of grade ≥II were considered AVN, a significant difference in the prevalence of AVN was found, with 15 (6%) cases of AVN in infants with the ossific nucleus compared with 28 (20%) without the ossific nucleus (0.34, 0.17 to 0.67). Subgroup analysis showed that the presence of the ossific nucleus reduced the probability of AVN by 70% (0.30, 0.14 to 0.62) in case of a closed reduction, but no significant effect was found for open reduction (0.87, 0.50 to 1.54). All studies demonstrated methodological weaknesses compromising the quality of evidence.

Conclusion: We could not demonstrate a significant effect of the ossific nucleus on the development of AVN. The meta-analysis suggested that the ossific nucleus might have a protective effect against the development of more severe forms of AVN.

Aim: To compare acetabular development and hip stability over time in patients treated for developmental dysplasia of the hip (DDH) by open reduction combined with either varusderotation (VDRO) or innominate (IO) osteotomies.

Method: Patients who underwent open reduction for DDH, combined with either VDRO (38 patients) or IO (33 patients), between 15 months and 4 years of age were reviewed. Both groups comprised a single surgeon consecutive series, differing only in the type of osteotomy performed. A total of 490 postoperative radiographs over a maximum follow-up period of 13.6 years were analyzed. We used repeated measures analysis of variance to compare the change in acetabular index (AI) as well as several other radiographic indices of acetabular development and hip stability over time.

Results: After osteotomy, the AI decreased in both groups but the magnitude of the decrease was significantly different between groups over time (p< 0.0001). The AI of patients undergoing VDRO never decreased as much as that of patients undergoing IO, with a mean difference of 10.4 degrees after 4 years (p< 0.0001). Similarly the IO group demonstrated more favourable acetabular architecture and hip stability over time compared to the VDRO group, as quantified by change in the acetabular floor thickness (p< 0.03), lateral centring ratio (p< 0.0001) and superior centring ratio (p < 0.0001).

Conclusions: Acetabular remodelling after IO was more effective at reversing acetabular dysplasia and maintaining hip stability than VDRO. Long-term follow-up of VDRO will be necessary to determine if late improvement occurs. IO may be preferable over VDRO in the treatment of hip dislocation after walking age.

Severe acetabular dysplasia with established dislocation of the hip represents a common problem in cerebral palsy. Once significant dysplasia is present little remodeling of the acetabulum occurs with femoral osteotomies alone. Pelvic osteotomies should address the problem of acetabular deficiency in order to restore optimal coverage of the femoral head. Standard innominate oste-otomies are not recommended for neuromuscular hip dysplasia. To address the lack of postero-lateral coverage in this population, a modified periacetabular osteotomy was performed.

Between 1991 and 2000 a total of forty-four patients (fifty-two hips) with total body involvement CP underwent this procedure at a mean age of nine, four yrs. The modification includes only one bicortical cut at the posterior corner at the sciatic notch. The cut extends down to the triradiate cartilage, if present, and through the former site of the triradiate cartilage after closure of the acetabular growth plate in adolescence. Additional procedures included: open reduction, femoral varus osteotomy, and soft tissue releases. Follow-up included a subjective and clinical evaluation. Radiographic assessment included measurements of the migration percentage and acetabular index, evidence of AVN, and premature closure of the triradiate cartilage.

The mean follow-up period for these patients was 3.5 years (1.0 to 8,1 yrs) after surgery, and 70% of the patients had reached skeletal maturity at that time. The median acetabular index improved from 30% pre-operatively to 18% at follow-up. The median migration percentage was 71% preoperatively, and zero at follow-up. A re-dislocation occurred in one hip, and a re-subluxation in another. All other hips were stable and well contained at follow-up. There were three hips showing signs of postoperative femoral head defects . Premature closure of the triradiate cartilage was not noted. The care-givers had the impression that the surgery had improved personal care, positioning/transferring, and comfort.

This osteotomy reduces the volume of the elongated acetabulum and provides coverage by articular cartilage. It provides coverage particularly at the posterior part of the acetabulum. Compared to other techniques this modified periacetabular osteotomy has only one posterior cortical cut which extends down to the sciatic notch. Since this cut is cortical, the fragment can be mobilized extensively and it allows placement of a graft and a better posterior coverage.

This study investigated the effect presence, method, and timing of fixation of femoral shaft fractures have on the morbidity and mortality of patients with pulmonary contusion.

In the multiply-injured patient with femoral shaft fractures, early (< 24 hours) fracture stabilization with closed, reamed, statically-locked intramedullary nailing has been shown to decrease morbidity and mortality. Controversy exists as to whether such treatment compromises the outcome in patients that have significant co-existing pulmonary injury. This study is the first to specifically investigate the sub-group of patients that have pulmonary contusion.

A retrospective review of patients presenting to a Level One trauma center from 1990 to 2002 with pulmonary contusion identified three hundred and twenty-two cases. Patient characteristics of age, sex, GCS, ISS, AIS, presence of femoral shaft fracture, method and timing of treatment of femoral shaft fracture, and presence of other pulmonary injuries were recorded, as were the outcomes of pulmonary complications (acute lung injury (ALI), ARDS, fat embolism syndrome, pulmonary embolism, and pneumonia), days on ventilatory support, days in the intensive care unit and ward, and death.

There were no significant differences in the patient characteristics between groups with and without femoral shaft fracture. Except for an increased likelihood of the femoral shaft fracture group having ALI (RR 1.11), there were no significant differences in outcomes between the femur fracture/non-femur fracture groups. As well, there were no significant differences in outcomes between the groups that had fracture fixation before or after twenty-four hours or had the fracture fixed with or without intramedullary nailing.

The presence, method, and timing of treatment of femoral shaft fractures do not increase the morbidity or mortality of trauma patients that have pulmonary contusion.

Objective: Severe acetabular dysplasia with established dislocation of the hip represents a common problem in cerebral palsy. Once significant dysplasia is present little remodeling of the acetabulum occurs with femoral osteotomies alone. Pelvic osteotomies should address the problem of acetabular deficiency in order to restore optimal coverage of the femoral head. Standard innominate osteotomies are not recommended for neuromus-cular hip dysplasia. To address the lack of postero-lateral coverage in this population, a modified periacetabular osteotomy was performed.

Methods: Between 1991 and 2000 a total of 44 patients (52 hips) with total body involvement CP underwent this procedure at a mean age of 9,4 yrs. The modification includes only one bicortical cut at the posterior corner at the sciatic notch. The cut extends down to the trira-diate cartilage, if present, and through the former site of the triradiate cartilage after closure of the acetabu-lar growth plate in adolescence. Additional procedures included: open reduction, femoral varus osteotomy, and soft tissue releases. Follow-up included a subjective and clinical evaluation. Radiographic assessment included measurements of the migration percentage and acetab-ular index, evidence of AVN, and premature closure of the triradiate cartilage.

Results: The mean follow-up period for these patients was 3.5 years (1.0 to 8,1 yrs) after surgery, and 70% of the patients had reached skeletal maturity at that time. The median acetabular index improved from 30% pre-operatively to 18% at follow-up. The median migration percentage was 71% preoperatively, and 0 at follow-up. A re-dislocation occurred in 1 hip, and a re-subluxation in another. All other hips were stable and well contained at follow-up. There were 3 hips showing signs of postoperative femoral head defects . Premature closure of the triradiate cartilage was not noted. The caregivers had the impression that the surgery had improved personal care, positioning/transferring, and comfort.

Conclusions: This osteotomy reduces the volume of the elongated acetabulum and provides coverage by articular cartilage. It provides coverage particularly at the posterior part of the acetabulum. Compared to other techniques this modified periacetabular osteotomy has only one posterior cortical cut which extends down to the sciatic notch. Since this cut is cortical, the fragment can be mobilized extensively and it allows placement of a graft and a better posterior coverage.

Primary skin closure after surgery for club foot in children can be difficult especially in revision operations. Between 1990 and 1996 a soft-tissue expander was implanted in 13 feet before such procedures. Two were primary operations and 11 were revisions. A standard technique was used for implantation of the expander. Skin augmentation was successful in 11 cases. There was failure of one expander and one case of wound infection. Sufficient stable skin could be gained at an average of five weeks. Primary skin closure after surgery was achieved in 12 cases.

We conclude that soft-tissue expansion can be used successfully before extensive surgery for club foot. The method should be reserved for revision procedures and for older children. The technique is not very demanding, but requires experience to achieve successful results.