We report the preliminary results of a continuing prospective evaluation of a screening programme for congenital dislocation of the hip (CDH) which uses ultrasound imaging to provide delayed selective screening to complement neonatal clinical screening. Of 26,952 births in the Southampton district, 1894 infants were referred for secondary screening because of a clinical abnormality or the presence of a predetermined risk category for CDH. Pavlik harness treatment was required for only 118 infants, giving a treatment rate of 4.4 per 1000 births. Of those referred with clinical instability, 35% did not require treatment. Dislocation or subluxation was detected in 17 of 643 infants referred only because they fell within one of three risk categories: breech presentation, foot deformity and family history. All 17 had normal clinical examinations and cases were discovered in each category. Six children presented with CDH after 12 weeks of age, giving a late presentation rate of 0.22 per 1000 births. All had normal clinical examinations within 24 hours of birth and none was in a risk category. Surgery has been required in ten children, giving a surgical treatment rate of 0.37 per 1000 births. We conclude that, in Southampton, delayed selective secondary screening with ultrasound is more effective than clinical screening alone. It targets treatment to those infants who need it, and reveals a number of dislocated and subluxed hips that would otherwise be missed

We investigated 29 cases, diagnosed clinically as having Morton’s neuroma, who had undergone MRI and ultrasound before a neurectomy. The accuracy with which pre-operative clinical assessment, ultrasound and MRI had correctly diagnosed the presence of a neuroma were compared with one another based on the histology and the clinical outcome.

Clinical assessment was the most sensitive and specific modality. The accuracy of the ultrasound and MRI was similar and dependent on size. Ultrasound was especially inaccurate for small lesions.

There was no correlation between the size of the lesion and either the pre-operative pain score or the change in pain score following surgery.

Reliance on single modality imaging would have led to inaccurate diagnosis in 18 cases and would have only benefited one patient. Even imaging with both modalities failed to meet the predictive values attained by clinical assessment.

There is no requirement for ultrasound or MRI in patients who are thought to have a Morton’s neuroma. Small lesions, < 6 mm in size, are equally able to cause symptoms as larger lesions. Neurectomy provides an excellent clinical outcome in most cases.

We examined ten femoral veins with duplex ultrasound during total hip replacement to demonstrate the operative manoeuvres which cause venous obstruction and to assess prophylactic measures which may overcome it. Exposure of the acetabulum by distraction of the femur with a hook was less likely to occlude flow than retraction with bone levers. Adequate exposure of the femoral shaft by adduction, flexion and either internal or external rotation caused cessation of flow in all cases. In four cases an A-V Impulse System foot pump was activated during periods of stasis. In each case it overcame the obstruction and produced peak velocities which were twice that of the resting state. In five cases, towards the end of the procedure, debris was seen travelling proximally through the femoral vein.

We describe a method of closed, unlocked nailing for femoral fractures using ultrasound instead of an image intensifier. Radiography was used only to confirm that the guide wire had been passed into the intramedullary canal of both fragments. The method succeeded in 26 of 30 cases. The failures all occurred in fractures which could not be reduced within 20 minutes. The operating time in those nailed successfully with ultrasound control was not different from the time for 30 control cases using conventional methods with an image intensifier.

Aims. The aim of this study was to assess the effectiveness of perioperative essential amino acid (EAA) supplementation to prevent rectus femoris muscle atrophy and facilitate early recovery of function after total knee arthroplasty (TKA). Methods. The study involved 60 patients who underwent unilateral TKA for primary knee osteo-arthritis (OA). This was a double-blind, placebo-controlled, randomized control trial with patients randomly allocated to two groups, 30 patients each: the essential amino acid supplementation (9 g daily) and placebo (lactose powder, 9 g daily) groups. Supplementation and placebo were provided from one week before to two weeks after surgery. The area of the rectus femoris muscle were measured by ultrasound imaging one month before surgery and one, two, three, and four weeks postoperatively. The serum albumin level, a visual analogue knee pain score, and mobility were also measured at each time point. The time to recovery of activities of daily living (ADLs) was recorded. Postoperative nutrition and physiotherapy were identical in both groups. Results. The mean relative change from baseline was as follows for the amino acid group: 116% in rectus femoris muscle area (71% to 206%); 95% in serum albumin (80% to 115%) and 39% in VAS pain (0% to 100%) at four weeks after surgery. These values in the placebo group were: 97% in muscle area (68 to 155); 89% in serum albumin (71% to 100%) and 56% in VAS pain four weeks after surgery (0% to 100%). All changes were statistically significant (p < 0.05). The mean time to recovery of ADLs was shorter in the amino acid group compared with the placebo group (p = 0.005). Conclusion. Perioperative essential amino acid supplementation prevents rectus femoris muscle atrophy and accelerates early functional recovery after TKA. Cite this article: Bone Joint J 2020;102-B(6 Supple A):10–18

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

We have examined the accuracy of 143 consecutive ultrasound scans of patients who subsequently underwent shoulder arthroscopy for rotator-cuff disease. All the scans and subsequent surgery were performed by an orthopaedic surgeon using a portable ultrasound scanner in a one-stop clinic. There were 78 full thickness tears which we confirmed by surgery or MRI. Three moderate-size tears were assessed as partial-thickness at ultrasound scan (false negative) giving a sensitivity of 96.2%. One partially torn and two intact cuffs were over-diagnosed as small full-thickness tears by ultrasound scan (false positive) giving a specificity of 95.4%. This gave a positive predictive value of 96.2% and a negative predictive value of 95.4%. Estimation of tear size was more accurate for large and massive tears at 96.5% than for moderate (88.8%) and small tears (91.6%). These results are equivalent to those obtained by several studies undertaken by experienced radiologists. We conclude that ultrasound imaging of the shoulder performed by a sufficiently-trained orthopaedic surgeon is a reliable time-saving practice to identify rotator-cuff integrity

Of the 34 723 infants born between 1 June 1992 and 31 May 2002, the hips of 2578 with clinical instability or at-risk factors for developmental dysplasia of the hip were imaged by ultrasound. Instability of the hip was present in 77 patients, of whom only 24 (31.2%) had an associated risk factor. From the ‘at-risk’ groups, the overall risk of type-III dysplasia, instability and irreducibility was 1:15 when family history, 1:27 when breech delivery and 1:33 when foot deformity were considered as risk factors. Of those hips which were ultrasonographically stable, 88 had type-III dysplasia. A national programme of selective ultrasound screening of at-risk factors for the diagnosis of hip dislocation or instability alone cannot be recommended because of its low predictive value (1:88). However, the incidence of type-III dysplasia and hip dislocation or dislocatability in the groups with clinical instability, family history, breech position and possibly postural foot deformity as risk factors could justify a programme of selective ultrasound imaging

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The aim of this study was to investigate the agreement in interpretation of the quality of the paediatric hip ultrasound examination, the reliability of geometric and morphological assessment, and the relationship between these measurements.

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Lateral femoral cutaneous nerve (LFCN) injury is a potential complication after the direct anterior approach for total hip arthroplasty (DAA-THA). The aim of this study was to determine how the location of the fasciotomy in DAA-THA affects LFCN injury.

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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.

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The Birmingham Hip Resurfacing (BHR) arthroplasty has been used as a surgical treatment of coxarthrosis since 1997. We present 20-year results of 234 consecutive BHRs performed in our unit.

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Radiological residual acetabular dysplasia (RAD) has been reported in up to 30% of children who had successful brace treatment of infant developmental dysplasia of the hip (DDH). Predicting those who will resolve and those who may need corrective surgery is important to optimize follow-up protocols. In this study we have aimed to identify the prevalence and predictors of RAD at two years and five years post-bracing.

The imaging techniques available to aid the diagnosis of ruptures of tendo Achillis, the rotator cuff and the tendon of tibialis posterior in rheumatoid patients are well described. However, ruptures of tendon or muscle at other sites are uncommon and may be overlooked. Diagnosis is often made by localised tenderness, swelling and a lack of active movement associated with a palpable defect. Clinical examination may be inconclusive and can be aided by imaging studies. We report two cases in which ruptures of a tendon were suspected, and ultrasound imaging demonstrated the palpable defect to be a cleavage plane in the subcutaneous fat – a ‘fat fracture’

In this prospective study of 18 hips we compared the efficacy of ultrasound with CT in determining the position of the femoral head in a spica cast after closed or open reduction in children with developmental dysplasia of the hip. Ultrasound was performed through the perineal opening of the cast. With a transinguinal approach, the superior ramus of the pubis, the acetabulum, the femoral head and the femoral neck can be depicted in one plane. The CT and ultrasound images were blinded and reviewed by two of the authors. Ultrasound was inconclusive in the first two reductions since the perineal opening was too small to see all the landmarks in one plane. In the following 16 reductions the landmarks were well defined and interpretation of the CT and ultrasound was similar. The perineal opening in the spica cast should be made in such a way that the ultrasound probe can be positioned in the groin so that the landmarks can be shown in one plane

We used ultrasonography to study 26 hips with slipped capital femoral epiphyses. In recently slipped epiphyses the ultrasound image revealed a step at the anterior physeal outline (mean 6.4 mm), diminished distance between the anterior acetabular rim and the femoral metaphysis (mean 4.3 mm) and an effusion. As metaphyseal remodelling progressed the physeal step decreased. The femoral neck appeared straighter in hips which had been symptomatic for longer than three weeks. It was possible to measure posterior epiphyseal displacement without projectional errors and the method was accurate in diagnosing minimal slip and in staging displacement. The suggested criteria are, less than 7 mm for a mild slip, 7 to 11 mm for a moderate slip and more than 11 mm for a severe slip. We recommend ultrasonography for the diagnosis, staging and follow-up management of slipped upper femoral epiphysis

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There is no consensus regarding optimum timing and frequency of ultrasound (US) for monitoring response to Pavlik harness (PH) treatment in developmental dysplasia of the hip (DDH). The purpose of our study was to determine if a limited-frequency hip US assessment had an adverse effect on treatment outcomes compared to traditional comprehensive US monitoring.

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Sarcopenia is characterized by a generalized progressive loss of skeletal muscle mass, strength, and physical performance. This systematic review primarily evaluated the effects of sarcopenia on postoperative functional recovery and mortality in patients undergoing orthopaedic surgery, and secondarily assessed the methods used to diagnose and define sarcopenia in the orthopaedic literature.