Simulated learning is increasingly prevalent in many surgical training programs as medical education moves towards competency based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated diagnosis where the standard of care in patients less than six months of age is an orthotic device such as the Pavlik Harness. However, despite widespread use of the Pavlik Harness and the potential complications that may arise from inappropriate application, no formal educational methods exist.

A video and model based simulated learning module for Pavlik Harness application was developed. Two novice groups (residents and allied health professionals) were exposed to the module and at pre-intervention, post-intervention and retention testing were evaluated on their ability to apply a Pavlik Harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skill (OSATS) and a Global Rating Scale (GRS) specific to Pavlik Harness application. A control group who did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik Harness alone would affect ability. All groups were compared to a group of clinical experts who were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t-tests and ANOVA.

Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik Harness (p<0.05) to the level of expert clinicians and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve nor did they achieve competency.

The simulated learning module has been shown to be an effective tool for teaching the application of a Pavlik Harness and learners demonstrated retainable skills post intervention. This learning module will form the cornerstone of formal teaching for Pavlik Harness application in developmental dysplasia of the hip.

Background

Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21. We describe long-term outcomes following precise use of the femoral varus derotation osteotomy to achieve and maintain hip stability and community ambulation.

Purpose

Habitual hip subluxation and dislocation is a potentially disabling feature of Trisomy 21 and we describe long-term outcomes following the precise use of femoral varus derotation osteotomy.

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).

Background

A consecutive series of 76 patients (101 hips) underwent primary open reduction, capsulorrhaphy and innominate osteotomy for late presenting developmental hip dislocation. They were aged 1.5 to 5 years at the time of surgery between 1958 and 1965. This study was designed to review their outcome into middle age.

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study. Standardised, well-centered anteroposterior standing hip radiographs were obtained and using the validated method of Hefti (1995), anterior and posterior acetabular coverage and contact area were measured. From this we were able to extrapalate the acetabular version.

Ten operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks.

Twenty-six hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B. 21 further age and sex matched AP pelvis radiographs were taken from the PACS system at random. All of which had been reported as normal by a consultant musculoskeletal radiologist, these formed group C.

The Kruskal Wallis test was used to compare the 4 outcomes, in the 3 groups.

A significant difference between the groups was found for contact area (p< 0.001). There was no significant difference between the other 3 outcomes. Anterior coverage (p=0.509), posterior coverage (p = 0.135) and antirversion (p= 0.845).

Conclusion: Acetabular coverage and anteversion in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. The early osteoarthritic changes seen in these hips may be related to a decreased contact area compared to the normal population. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.

Introduction: A criticism of innominate osteotomy (IO) is that it causes relative acetabular retroversion, predisposing to OA. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients 45 years after they had undergone open reduction and innominate osteotomy for late presenting DDH. Using the validated method of Hefti (1995) we measured anterior and posterior acetabular coverage, contact area and version.

Results: Group 1 – 26 Post-op hips, Group 2 – 20 Contralateral hips, Group 3 – 21 Normal hips. Anterior coverage was 10.8% in group 1, 11.0% in group 2 and 12.0% in group 3. Posterior coverage was 18.8% in group 1, 18.9% in group 2 and 21.0% in group 3. Contact area was 16.1 cm2 in group 1, 13.9 cm2 in group 2, and 22.1 cm2 in group 3. Version was 7.20 in group 1, 7.10 in group 2, and 7.70 in group 3.

A significant difference was found for contact area (p< 0.001). There was no significant difference in version (p = 0.845).

Conclusion: Early OA may be related to contact area. Any abnormal (retro)version grows out. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.

Introduction: A criticism of innominate osteotomy is that it causes relative acetabular retroversion, predisposing to osteoarthritis. This study was designed to address this hypothesis.

Materials and Methods: We had access to radiographs of 30 patients that had undergone open reduction and innominate osteotomy for late presenting developmental hip dislocation. The patients are now middle-aged and formed part of a previously reported study on the long term outcome of this protocol. Standardised, well-centered anteroposterior standing hip radiographs had been obtained. We used the validated method of Hefti (1995) to measure anterior and posterior acetabular coverage and contact area. All measurements were made by a single independent investigator.

Results: 10 operated hips had advanced osteoarthritis which made it impossible to identify acetabular landmarks. 26 hips were readable despite signs of mild to moderate osteoarthritis in some (Group A). 20 contra-lateral hips without DDH which appeared radiographically normal formed control group B.

Discussion: We were unable to assess operated hips which had gone on to replacement or severe osteoarthritis. This is a flaw as those hips with better radiographs have been selected out for study. Nonetheless this was a unique opportunity to assess the effect of innominate osteotomy on acetabular development in good numbers of hips with a variety of evolved outcomes.

Conclusion: Acetabular coverage and load area in hips with a good outcome after innominate osteotomy with open reduction were not different to a control group of radiographically normal hips without previous DDH. Innominate osteotomy before the age of 5 years has the potential to facilitate, or at least not prevent, normal acetabular development and version.

Purpose: Background: Treatment of Legg-Perthes disease in older children with greater involvement of the femoral head remains uncertain. Innominate or combined innominate and femoral osteotomies are generally performed to better contain and provide more coverage of the femoral head by the acetabulum and thus achieve a more spherical head and a congruent joint. The purpose of the study was to show the results of both surgeries.

Methods: We carried out a retrospective review of 43 hips in 41 patients (36 males, 5 females), with lateral pillar classifications of B (25 hips), B/C (12), and C (6), who had not responded to non-surgical treatment and all treated by one surgeon. They underwent Salter innominate (23 hips) or combined innominate and femoral osteotomies (20 hips). Mean age of the former group at surgery was 7 years, 11 months and of the latter, 10 years, 7 months. Combined osteotomy was performed in older children with more head involvement and stiff hips that did not respond to other treatments. Patients were evaluated with a mean follow-up of 9 years, 4 months using the Stulberg radiographic assessment.

Results: Results: Stulberg I or II (SI-SII) results were attained by 57% of the innominate osteotomy group and 30% of the combined. Eleven of 14 LPB hips in the innominate group and 5 of 11 in the combined became SI-II in contrast to 2 of 5 and 1 of 7 LPB/C hips, respectively. All 6 LPC hips were classified Stulberg III or IV (SIII-IV). Children younger than 8 years in the innominate group had better results than the older children (65% vs 33%) and those younger than 10 in the combined group did better than the older (43% vs 0%).

Conclusions: Conclusions: The LPB and LPB/C groups treated by innominate osteotomy had better results (more spherical heads) than those undergoing combined osteotomy, age proving a stronger prognostic factor than disease stage. The LPC led to aspherical congruent hips with either type of surgery, regardless of patient’s age. The outcome was better in LPB in children younger than 8 years of age and in LPB/C in those older than 8 years. Age of onset still remains the primary determinant of outcome in LCPD.

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.

Aims: The purpose of this retrospective study was to determine if open reduction, with pelvic and femoral osteotomy, for a dislocated hip in children with severe spastic quadriplegia alters the function or symptoms of the patient and to determine radiographic factors that correlate with sypmtoms. Methods: The validated Pediatric Evaluation of Disability Inventory (PEDI) and a self-constructed questionnaire asking about pain, hygiene, sitting status and ambulatory status were sent to the caregivers of 52 patients who were operated on. Radiographs were reviewed for changes in centre edge angle, acetabular index, migration index and femoral head defect. Results: 27 caregivers completed the questionnaires. Complete pre-operative radiographs and radiographs from latest follow-up were available in 42 patients and complete radiographs and completed questionnaires were available for 21 patients. The average age at surgery was 9 years with a mean follow-up of 5.5 years. The results of the PEDI did not change signiþcantly following surgery. The second questionnaire showed an improvement of hygiene care for 11 patients, weight bearing for transfers for seven, sitting status for 10 and sitting tolerance for 18. Pain improved for 17 and deteriorated for two patients. There was no correlation between radiographic measures and function or symptoms. Conclusions: Open reduction with pelvic and femoral osteotomy for dislocated hips in children with severe cerebral palsy can result in a decrease in pain and a modest improvement in function.

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.

The purpose of this retrospective study was to determine if open reduction, with pelvic and femoral osteotomy, for a dislocated hip in children with severe spastic quadriplegia alters the function or symptoms of the patient, and to determine radiographic factors that correlate with symptoms.

Between 1989 and 1997 56 patients/hips were operated on. The validated Pediatric Evaluation of Disability Inventory (PEDI) and a self-constructed questionnaire asking about pain, hygiene, sitting status, sitting tolerance, weight bearing for transfers, and ambulatory status were sent to all families. Radiographs were reviewed for changes in the centre edge angle (CE), acetabular index (AI), migration index (MI) and femoral head defect (FHD). 27 caregivers completed the questionnaires. Radiographs (pre-operative – latest follow-up) were available for 42 patients. 21 patients had both questionnaire and radiograph information.

Logistic regressions were used to test whether the radiographic measures could predict each of the questionnaire outcomes which were grouped as ‘improved’ and ‘not improved’.

The average age at surgery was 8.9 years (n=56: 1.8 – 16.5) for all patients, for patients with a completed questionnaire 9.4 years (n=27: 4.2–15.4). Time from surgery to follow-up was in average 5.5 years (1.8–9.5).

All but 2 of the patients with completed questionnaire were nonambulatory (2 were functional ambulatory). As a group, the results of the PEDI did not significantly change following surgery. From the results of the second questionnaire: hygiene care improved for 11 patients, weight bearing for transfers improved for 7, sitting status improved for 10, and sitting tolerance improved for 18 patients.

At follow-up, pain worsened in 2 patients, did not improve in 2 patients, and the remainder were pain free. The ability to provide hygiene care worsened for the 2 patients with worsening pain. Weight bearing for transfers and sitting status worsened in 3 patients, 2 of who were the patients with worsening pain, and the other had an unreduced dislocation of the opposite hip. Sitting tolerance worsened in 3 patients, 2 of who were the patients with worsening pain.

Four patients who did not have femoral head defects prior to surgery developed them after surgery. Two of these four patients were the ones who developed worsening pain but had normal CE, AI and MI measures. Other radiographic measures of the hips did not correspond with function or symptoms. Eight patients had a femoral head defect prior to surgery and none were symptomatic at follow-up.

Our assessment method shows that open reduction for the dislocated hip in children with severe cerebral palsy can result in a decrease in pain and a modest improvement in function. However, the postoperative development of a femoral head defect is associated with worse pain and poorer function. A pre-existing femoral head defect is not a contraindication to surgery.

A longitudinal incision resembling a bucket-handle tear was made in the menisci of 8 rabbits, 6 dogs, 11 pigs and 12 sheep. In some of the animals of each species the cut was repaired by suturing, and in others it was not. Gross inspection, as well as examination by light and electron microscopy, showed that no healing had occurred after six months in the sutured or the unsutured wounds and that the meniscus was incapable of significant intrinsic repair. In a second experiment longitudinal, transverse and T-shaped cuts were made in the menisci of 12 sheep, and a flap of synovium was sutured into the wound. Three months later there was clear evidence of healing by the formation of cartilaginous tissue. Examination by light and electron microscopy showed that the newly formed repair tissue, possibly derived by metaplasia from the synovium, had a morphology intermediate between hyaline cartilage and fibrocartilage. Synovial implantation may therefore be considered as an alternative to meniscectomy in the management of the torn meniscus.

Fifty-four adults with eighty hips affected by congenital disease which had not been treated have been reviewed. Fifty-nine per cent of forty-two dislocated hips had fair or poor grading scores. The incidence of osteoarthritis was markedly increased in the presence of a well-developed false acetabulum. Unilateral dislocation led to valgus deformity and degenerative changes in the ipsilateral knee in seven of twenty-two patients. Dislocation did not increase the incidence of symptomatic lumbar spondylosis. The height of the dislocated head on the ilium was not found to be related to the prognosis for the hip, the knee or the lumbar spine and did not correlate with the development of the false acetabulum. Frank congenital subluxation eventually led to osteoarthritis of the hip.