The February 2024 Children’s orthopaedics Roundup. 360. looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures

Aims

To analyze whether the addition of risk-based criteria to clinical examination-based selective ultrasound screening would increase the rates of early detected cases of developmental dysplasia of the hip (DDH) and decrease the rate of late detected cases.

Aims

The aim of this study was to compare outcomes of guided growth and varus osteotomy in treating Kalamchi type II avascular necrosis (AVN) after open reduction and Pemberton acetabuloplasty for developmental dysplasia of the hip (DDH).

Aims

The aim of this study was to evaluate the epidemiology and treatment of Perthes’ disease of the hip.

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Aims

To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures.

Aims

We aimed to determine hip-related quality of life and clinical findings following treatment for neonatal hip instability (NHI) compared with age- and sex-matched controls. We hypothesized that NHI would predispose to hip discomfort in long-term follow-up.

Aims

Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group.

Aims

The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant.

Aims

The goal of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) is to achieve and maintain concentricity of the femoral head in the acetabulum. However, concentric reduction is not immediately attainable in all hips and it remains controversial to what degree a non-concentric reduction is acceptable. This prospective study is aimed at investigating the dynamic evolution of the hip joint space after CR in DDH using MRI.

Aims

When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity.

Aims

The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods.

Aims

The purpose of this study was to analyze the incidence of the different ultrasound phenotypes of developmental dysplasia of the hip (DDH), and to determine their subsequent course.

Aims

The significance of the ‘clicky hip’ in neonatal and infant examination remains controversial with recent conflicting papers reigniting the debate. We aimed to quantify rates of developmental dysplasia of the hip (DDH) in babies referred with ‘clicky hips’ to our dedicated DDH clinic.

Aims

Open reduction is required following failed conservative treatment of developmental dysplasia of the hip (DDH). The Ludloff medial approach is commonly used, but poor results have been reported, with rates of the development of avascular necrosis (AVN) varying between 8% and 54%. This retrospective cohort study evaluates the long-term radiographic and clinical outcome of dislocated hips treated using this approach.

Aims

The aim of this study was to identify the association between asymmetrical skin creases of the thigh, buttock or inguinal region and pathological developmental dysplasia of the hip (DDH).

Patients with neuromuscular imbalance who require total hip arthroplasty (THA) present particular technical problems due to altered anatomy, abnormal bone stock, muscular imbalance and problems of rehabilitation.

In this systematic review, we studied articles dealing with THA in patients with neuromuscular imbalance, published before April 2017. We recorded the demographics of the patients and the type of neuromuscular pathology, the indication for surgery, surgical approach, concomitant soft-tissue releases, the type of implant and bearing, pain and functional outcome as well as complications and survival.

Recent advances in THA technology allow for successful outcomes in these patients. Our review suggests excellent benefits for pain relief and good functional outcome might be expected with a modest risk of complication.

Cite this article: Bone Joint J 2018;100-B(1 Supple A):17–21.

Aims

The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England.

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.

Aims

This study compared the long-term results following Salter osteotomy and Pemberton acetabuloplasty in children with developmental dysplasia of the hip (DDH). We assessed if there was a greater increase in pelvic height following the Salter osteotomy, and if this had a continued effect on pelvic tilt, lumbar curvature or functional outcomes.

Aim

Until now, there has been no consensus as to whether stemmed acetabular components are appropriate for use in patients undergoing revision total hip arthroplasty (THA) who have major acetabular defects or pelvic discontinuity. We wished to address this deficiency in the literature.

The aims of this study were to report functional outcomes of salvage procedures for patients with cerebral palsy (CP) who have chronic dislocation of the hip using validated scoring systems, and to compare the results of three surgical techniques.

We reviewed 37 patients retrospectively. The mean age at the time of surgery was 12.2 years (8 to 22) and the mean follow-up was 56 months (24 to 114). Patients were divided into three groups: 14 who underwent proximal femoral resection arthroplasty (PFRA group 1), ten who underwent subtrochanteric valgus osteotomy (SVO group 2), and 13 who underwent subtrochanteric valgus osteotomy with resection of the femoral head (SVO with FHR group 3). All patients were evaluated using the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD) and the Pediatric Quality of Life Inventory (PedsQL).

Significant improvements occurred in most CPCHILD and PedsQL subsection scores following surgery in all patients, without significant differences between the groups. There were 12 post-operative complications. Less severe complications were seen in group 1 than in groups 2 and 3.

Salvage surgery appears to provide pain relief in patients with CP who have painful chronic dislocation of the hip. The three salvage procedures produced similar results, however, we recommend the use of PFRA as the complications are less severe.

Take home message: Salvage surgery can be of benefit to patients with CP with chronic painful hip dislocation, but should be limited to selected patients considering complications.

Cite this article: Bone Joint J 2016;98-B:137–43.

Successful management of late presenting hip dislocation in childhood is judged by the outcome not just at skeletal maturity but well beyond into adulthood and late middle age. This review considers different methods of treatment and looks critically at the handful of studies reporting long-term follow-up after successful reduction.

Cite this article: Bone Joint J 2015;97-B:729–33.

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Cite this article: Bone Joint J 2015; 97-B:442–8.

Over a 15-year prospective period, 201 infants with a clinically unstable hip at neonatal screening were subsequently reviewed in a ‘one stop’ clinic where they were assessed clinically and sonographically. Their mean age was 1.62 weeks (95% confidence interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value (PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic sonography for Graf type IV dysplastic hips had a 15-year sensitivity of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean, 99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI 41.6 to 68.5). There were 36 infants with an irreducible dislocation of the hip (0.57 per 1000 live births), including six that failed to resolve with neonatal splintage.

Most clinically unstable hips referred to a specialist clinic are female and stabilise spontaneously. Most irreducible dislocations are not identified from this neonatal instability group. There may be a small subgroup of females with instability of the hip which may be at risk of progression to irreducibility despite early treatment in a Pavlik harness.

A controlled study is required to assess the value of neonatal clinical screening programmes.

Cite this article: Bone Joint J 2015;97-B:265-9.

The December 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: predicting drift in supracondylar fractures; do normal hips dislocate?; the burden of trampoline fractures; muscle eversion activity is strongly predictive of outcome in CTEV; the modified Dunn osteotomy; plaster and moulded casts; and psychology and fractures.

The medial approach for the treatment of children with developmental dysplasia of the hip (DDH) in whom closed reduction has failed requires minimal access with negligible blood loss. In the United Kingdom, there is a preference for these children to be treated using an anterolateral approach after the appearance of the ossific nucleus. In this study we compared these two protocols, primarily for the risk of osteonecrosis.

Data were gathered prospectively for protocols involving the medial approach (26 hips in 22 children) and the anterolateral approach (22 hips in 21 children) in children aged <  24 months at the time of surgery. Osteonecrosis of the femoral head was assessed with validated scores. The acetabular index (AI) and centre–edge angle (CEA) were also measured.

The mean age of the children at the time of surgery was 11 months (3 to 24) for the medial approach group and 18 months (12 to 24) for the anterolateral group, and the combined mean follow-up was 70 months (26 to 228). Osteonecrosis of the femoral head was evident or asphericity predicted in three of 26 hips (12%) in the medial approach group and four of 22 (18%) in the anterolateral group (p = 0.52). The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to 10°), respectively, at two years post-operatively (p = 0.18). There was no significant difference in CEA values of affected hips between the two groups.

Children treated using an early medial approach did not have a higher risk of developing osteonecrosis at early to mid-term follow-up than those treated using a delayed anterolateral approach. The rates of acetabular remodelling were similar for both protocols.

Cite this article: Bone Joint J 2014;96-B:406–13.

The incidence of clinically significant avascular necrosis (AVN) following medial open reduction of the dislocated hip in children with developmental dysplasia of the hip (DDH) remains unknown. We performed a systematic review of the literature to identify all clinical studies reporting the results of medial open reduction surgery. A total of 14 papers reporting 734 hips met the inclusion criteria. The mean follow-up was 10.9 years (2 to 28). The rate of clinically significant AVN (types 2 to 4) was 20% (149/734). From these papers 221 hips in 174 children had sufficient information to permit more detailed analysis. The rate of AVN increased with the length of follow-up to 24% at skeletal maturity, with type 2 AVN predominating in hips after five years’ follow-up. The presence of AVN resulted in a higher incidence of an unsatisfactory outcome at skeletal maturity (55% vs 20% in hips with no AVN; p < 0.001). A higher rate of AVN was identified when surgery was performed in children aged < 12 months, and when hips were immobilised in ≥ 60°of abduction post-operatively. Multivariate analysis showed that younger age at operation, need for further surgery and post-operative hip abduction of ≥ 60° increased the risk of the development of clinically significant AVN.

Cite this article: Bone Joint J 2014;96-B:279–86.

Objectives

There are several reports clarifying successful results following open reduction using Ludloff’s medial approach for congenital (CDH) or developmental dislocation of the hip (DDH). This study aimed to reveal the long-term post-operative course until the period of hip-joint maturity after the conventional surgical treatments.

Most centres in the United Kingdom adopt a selective screening programme for developmental dysplasia of the hip (DDH) based on repeated clinical examination and selective ultrasound examination. The Newborn Infant Physical Examination protocol implemented in 2008 recommends a first examination at birth and then a second and final examination at six to ten weeks of age. Due to concerns over an increase in late presentations we performed a retrospective review of our 15-year results to establish if late presentation increases treatment requirements. Of children presenting before six weeks of age, 84% were treated successfully with abduction bracing, whereas 86% of children presenting after ten months eventually required open reduction surgery. This equates to a 12-fold increase in relative risk of requiring open reduction following late presentation. Increasing age at presentation was associated with an increase in the number of surgical procedures, which are inevitably more extensive and complex, with a consequent increased in cost per patient. The implementation of an opportunistic examination at three to five months could help to reduce the unintended consequences of the Newborn Infant Physical Examination programme.

Cite this article: Bone Joint J 2013;95-B:846–50.

The October 2012 Children’s orthopaedics Roundup³⁶⁰ looks at: magnetic growing rods and scoliosis correction; maintaining alignment after manipulation of a radial shaft fracture; Glaswegian children and swellings of obscure origin; long-term outcome of femoral derotation osteotomy in cerebral palsy; lower-leg fractures and compartment syndrome in children; fractures of the radial neck in children; management of the paediatric Monteggia fracture; and missing the dislocated hip in Western Australia.

The painful subluxed or dislocated hip in adults with cerebral palsy presents a challenging problem. Prosthetic dislocation and heterotopic ossification are particular concerns. We present the first reported series of 19 such patients (20 hips) treated with hip resurfacing and proximal femoral osteotomy. The pre-operative Gross Motor Function Classification System (GMFCS) was level V in 13 (68%) patients, level IV in three (16%), level III in one (5%) and level II in two (11%). The mean age at operation was 37 years (13 to 57).

The mean follow-up was 8.0 years (2.7 to 11.6), and 16 of the 18 (89%) contactable patients or their carers felt that the surgery had been worthwhile. Pain was relieved in 16 of the 18 surviving hips (89%) at the last follow-up, and the GMFCS level had improved in seven (37%) patients. There were two (10%) early dislocations; three hips (15%) required revision of femoral fixation, and two hips (10%) required revision, for late traumatic fracture of the femoral neck and extra-articular impingement, respectively. Hence there were significant surgical complications in a total of seven hips (35%). No hips required revision for instability, and there were no cases of heterotopic ossification.

We recommend hip resurfacing with proximal femoral osteotomy for the treatment of the painful subluxed or dislocated hip in patients with cerebral palsy.

In skeletally immature patients, resection of bone tumours and reconstruction of the lower limb often results in leg-length discrepancy. The Stanmore non-invasive extendible endoprosthesis, which uses electromagnetic induction, allows post-operative lengthening without anaesthesia. Between 2002 and 2009, 55 children with a mean age of 11.4 years (5 to 16) underwent reconstruction with this prosthesis; ten patients (18.2%) died of disseminated disease and one child underwent amputation due to infection. We reviewed 44 patients after a mean follow-up of 41.2 months (22 to 104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to 30) and the Toronto Extremity Salvage score was 92.3% (55.2% to 99.0%). There was no local recurrence of tumour. Complications developed in 16 patients (29.1%) and ten (18.2%) underwent revision.

The mean length gained per patient was 38.6 mm (3.5 to 161.5), requiring a mean of 11.3 extensions (1 to 40), and ten component exchanges were performed in nine patients (16.4%) after attaining the maximum lengthening capacity of the implant. There were 11 patients (20%) who were skeletally mature at follow-up, ten of whom had equal leg lengths and nine had a full range of movement of the hip and knee.

This is the largest reported series using non-invasive extendible endoprostheses after excision of primary bone tumours in skeletally immature patients. The technique produces a good functional outcome, with prevention of limb-length discrepancy at skeletal maturity.

Revision after failed femoral components may be technically demanding due to loss of peri-prosthetic bone. This retrospective study evaluated the long-term results of femoral revision using the cementless Wagner Self-Locking stem. Between 1992 and 1998, 68 consecutive hips in 66 patients underwent femoral revision using this implant. A total of 25 patients died from unrelated causes without further revision; the remaining 41 hips in 41 patients (12 men and 29 women) with a mean age of 61 years (29 to 80) were reviewed at a mean follow-up of 13.9 years (10.4 to 15.8). A transfemoral approach was used in 32 hips. A total of five stems required further revision because of infection in two, progressive subsidence in two and recurrent dislocation in one. Four hips had dislocated and eight stems had subsided ≥ 10 mm. The mean Harris hip score improved from 33 points pre-operatively to 75 points at final follow-up (p < 0.001). In all, 33 stems (91.7%) showed radiological signs of stable bone fixation. The cumulative survival rates at 15.8 years with femoral revision for any reason and for stem failure as the endpoints were 92.0% (95% confidence interval (CI) 86.0% to 98.4%) and 96.6% (95% CI 92.2% to 100%), respectively. The survivorship with revision and ≥ 10 mm migration of the stem as the endpoint was 83.6% (95% CI 76.6% to 91.4%).

This study shows quite good survival and moderate clinical outcome when using a monoblock tapered titanium stem for supporting the regeneration of bone in complex revision hip surgery.

Developmental dysplasia of the hip predisposes to premature degenerative hip disease. A number of operations have been described to improve acetabular cover and have achieved varying degrees of success. We present the case of an 84-year-old woman, who underwent a shelf procedure to reconstruct a dysplastic hip 75 years ago. To date, the shelf remains intact and the hip is asymptomatic. We believe this represents the longest documented outcome of any procedure to stabilise the hip.

We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature.

Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts.

We have investigated whether early anatomical open reduction and internal fixation (ORIF) reduces the incidence of complications of fracture of the femoral neck in children, including avascular necrosis, compared with closed reduction and internal fixation (CRIF). We retrospectively reviewed 27 such fractures (15 type-II and 12 type-III displaced fractures) in children younger than 16 years of age seen in our hospital between February 1989 and March 2007. We divided the patients into three groups according to the quality of the reduction (anatomical, acceptable, and unacceptable) and the clinical results into two groups (satisfactory and unsatisfactory). Of the 15 fractures treated by ORIF, 14 (93.3%) had anatomical reduction and reduction was acceptable in one. Of the 12 treated by CRIF, three (25.0%) had anatomical reduction, eight had acceptable reduction (66.7%), and one (8.3%) unacceptable reduction. Of the 15 fractures treated by ORIF, 14 (93.3%) had a good result and one a fair result. Of the 12 treated by CRIF, seven (58.3%) had a good result, two (16.7%) a fair result and three (25.0%) a poor result. There were seven complications in five patients.

ORIF gives better reduction with fewer complications, including avascular necrosis, than does CRIF in fractures of the femoral neck in children.

Internal hemipelvectomy is a standard treatment for malignant tumours of the pelvis. Reconstruction using a non-vascularised fibular graft is relatively straightforward compared to other techniques. We describe the surgical and functional outcomes for a series of ten patients who underwent an internal hemipelvectomy (type I or I/IV) with reconstruction by a non-vascularised fibular graft between 1996 and 2009. A key prerequisite for this procedure was a preserved sciatic notch, confirmed pre-operatively on MRI.

Graft-host union was achieved in all patients with a single fibular graft, and in the lower graft where two grafts had been used. The mean time to union was 7.3 months (3 to 12). The upper graft did not unite in four of six cases where two grafts had been used. Seven patients were eventually able to walk without a stick. The mean post-operative Musculoskeletal Tumour Society score was 75.4% (16.7 to 96.7). There were no cases of deep post-operative infection. The mean pelvic shortening was 0.9 cm (0.2 to 3.4). Recurrent tumour occurred in three cases, and death from tumour-related disease occured in one.

Patients who need an internal hemipelvectomy will do well if their pelvic ring is reconstructed with a non-vascularised fibular graft. The complication rate is low, and they attain a good functional outcome.

We present the results of treatment of developmental dysplasia of the hip in infancy with the Pavlik harness using a United Kingdom screening programme with ultrasound-guided supervision. Initially, 128 consecutive hips in 77 patients were reviewed over a 40-month period; 123 of these were finally included in the study. The mean age of the patients at the start of treatment was five weeks (1 to 12). All hips were examined clinically and monitored with ultrasound scanning. Failure of treatment was defined as an inability to maintain reduction with the harness. All hips diagnosed with dysplasia or subluxation but not dislocation were managed successfully in the harness. There were 43 dislocated hips, of which 39 were reducible, but six failed treatment in the harness. There were four dislocated but irreducible hips which all failed treatment in the harness. One hip appeared to be successfully treated in the harness but showed persistent radiological dysplasia at 12 and 24 months. Grade 1 avascular necrosis was identified radiologically in three patients at 12 months.

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique.

At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).

Femoroacetabular impingement causes pain in the hip in young adults and may predispose to the development of osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis of the hip and may have a role in that of femoroacetabular impingement. We compared 96 siblings of 64 patients treated for primary impingement with a spouse control group of 77 individuals. All the subjects were screened clinically and radiologically using a standardised protocol for the presence of cam and pincer deformities and osteoarthritis.

The siblings of those patients with a cam deformity had a relative risk of 2.8 of having the same deformity (66 of 160 siblings hips versus 23 of 154 control hips, p < 0.00001). The siblings of those patients with a pincer deformity had a relative risk of 2.0 of having the same deformity (43 of 116 sibling hips versus 29 of 154 control hips, p = 0.001). Bilateral deformity occurred more often in the siblings (42 of 96 siblings versus 13 of 77 control subjects, relative risk 2.6, p = 0.0002). The prevalence of clinical features in those hips with abnormal morphology was also greater in the sibling group compared with the control group (41 of 109 sibling hips versus 7 of 46 control hips, relative risk 2.5, p = 0.007). In 11 sibling hips there was grade-2 osteoarthritis according to Kellgren and Lawrence versus none in the control group (p = 0.002).

Genetic influences are important in the aetiology of primary femoroacetabular impingement. This risk appears to be manifested through not only abnormal joint morphology, but also through other factors which may modulate progression of the disease.

Neurological conditions affecting the hip pose a considerable challenge in replacement surgery since poor and imbalanced muscle tone predisposes to dislocation and loosening. Consequently, total hip replacement (THR) is rarely performed in such patients. In a systematic review of the literature concerning THR in neurological conditions, we found only 13 studies which described the outcome. We have reviewed the evidence and discussed the technical challenges of this procedure in patients with cerebral palsy, Parkinson’s disease, poliomyelitis and following a cerebrovascular accident, spinal injury or development of a Charcot joint. Contrary to traditional perceptions, THR can give a good outcome in these often severly disabled patients.

We evaluated radiological hip remodelling after shelf acetabuloplasty and sought to identify prognostic factors in 25 patients with a mean age of 8.9 years (7.0 to 12.3) who had unilateral Perthes’ disease with reducible subluxation of the hip in the fragmentation stage.

At a mean follow-up of 6.7 years (3.2 to 9.0), satisfactory remodelling was observed in 18 hips (72%). The type of labrum in hip abduction, as determined by intra-operative dynamic arthrography, was found to be a statistically significant prognostic factor (p = 0.012).

Shelf acetabuloplasty as containment surgery seems to be best indicated for hips in which there is not marked collapse of the epiphysis and in which the extruded epiphyseal segment slips easily underneath the labrum on abduction, without imposing undue pressure on the lateral edge of the acetabulum.

Slipped upper femoral epiphysis (SUFE) with an open physis is rare in an adult and the condition may present without prior diagnosis of an underlying medical condition. We have treated a 29-year-old man with bilateral SUFE associated with autoimmune hypothyroidism. The management was delayed and complicated by co-existing autoimmune chronic active hepatitis. He underwent thyroxine therapy and bilateral pinning in situ with a single ASNIS screw. Closure of the physis occurred after five months on the right side. The left side required a further corrective intertrochanteric osteotomy, and it was only after 13 months that complete fusion of this physis was seen. The case highlights the need to consider endocrine and metabolic conditions in atypical presentation of SUFE.

Since September 1964, neonates born in New Plymouth have undergone clinical examination for instability of the hip in a structured clinical screening programme. Of the 41 563 babies born during this period, 1639 were diagnosed as having unstable hips and 663 (1.6%) with persisting instability were splinted, five of which failed. Also, three unsplinted hips progressed to congenital dislocation, and there were four late-presenting (walking) cases, giving an overall failure rate of 0.29 per 1000 live births, with an incidence of late-walking congenital dislocation of the hip of 0.1 per 1000 live births.

This study confirms that clinical screening for neonatal instability of the hip by experienced orthopaedic examiners significantly reduces the incidence of late-presenting (walking) congenital dislocation of the hip.