It has recently been reported that the transverse acetabular ligament (TAL) is helpful in determining the position of the acetabular component in total hip replacement (THR). In this study we used a computer-assisted navigation system to determine whether the TAL is useful as a landmark in THR. The study was carried out in 121 consecutive patients undergoing primary THR (134 hips), including 67 dysplastic hips (50%). There were 26 men (29 hips) and 95 women (105 hips) with a mean age of 60.2 years (17 to 82) at the time of operation. After identification of the TAL, its anteversion was measured intra-operatively by aligning the inferomedial rim of the trial acetabular component with the TAL using computer-assisted navigation. The TAL was identified in 112 hips (83.6%). Intra-observer reproducibility in the measurement of anteversion of the TAL was high, but inter-observer reproducibility was moderate. . Each surgeon was able to align the trial component according to the target value of the angle of anteversion of the TAL, but it was clear that methods may differ among surgeons. Of the measurements of the angle of anteversion of the TAL, 5.4% (6 of 112 hips) were outliers from the safe zone. In summary, we found that the TAL is useful as a landmark when implanting the acetabular component within the safe zone in almost all hips, and to prevent it being implanted in retroversion in all hips, including dysplastic hips. However, as anteversion of the TAL may be excessive in a few hips, it is advisable to pay attention to individual variations, particularly in those with severe posterior pelvic tilt. Cite this article: Bone Joint J 2014;96-B:306–11

Aims. The aim of this study was to review the value of accepting referrals for children with ‘clicky hips’ in a selective screening programme for hip dysplasia. Patients and Methods. A single-centre prospective database of all referrals to the hip clinic was examined to identify indication for referrals, diagnosis, and treatment. All patients referred received a standardized ultrasound scan and clinical examination by an orthopaedic consultant. Results. There were 5716 children referred to the orthopaedic hip clinic between 1 June 2014 and 26 September 2018. In all, 1754 children (30.1%) were referred due to ‘clicky hip’ with no additional risk factors or indications for ultrasound scan. A total of 123 children (7.1%) referred with ‘clicky hip’ and no additional risk factors or examination findings had an abnormal initial hip ultrasound, including 16 children (0.9%) with dysplastic hips. Of the 141 children who required treatment in a Pavlik harness during the study period, 23 (16%) had been referred with a ‘clicky hip’ and no additional risk factors or examination findings, including six children with Graf 3 or 4 hips. Conclusion. There is significant value in reviewing children with an isolated ‘clicky hip’. Many children who require treatment are referred to the orthopaedic service as ‘clicky hip’ with no additional risk factors. In a pragmatic pathway with a diverse population of clinicians performing baby checks, ‘clicky hip’ is an important indication for referral and should not be discarded. Cite this article: Bone Joint J 2019;101-B:635–638

Aims. The aim of this study was to report the long-term results of rotational acetabular osteotomy (RAO) for symptomatic hip dysplasia in patients aged younger than 21 years at the time of surgery. Patients and Methods. We evaluated 31 patients (37 hips) aged younger than 21 years at the time of surgery retrospectively. There were 29 female and two male patients. Their mean age at the time of surgery was 17.4 years (12 to 21). The mean follow-up was 17.9 years (7 to 30). The RAO was combined with a varus or valgus femoral osteotomy or a greater trochanteric displacement in eight hips, as instability or congruence of the hip could not be corrected adequately using RAO alone. Results. The mean Merle d’Aubigné clinical score improved significantly from 15.4 to 17.2 (p < 0.0001). The mean centre-edge (CE) angle improved from -2.6° to 26°, the mean acetabular roof angle improved from 3.0° to 5.2°, and the mean head lateralization index improved from 0.68 to 0.62. Progression of radiological osteoarthritis (OA) was seen in seven hips, but no patient underwent total hip arthroplasty. Conclusion. RAO is an effective form of correction for a severely dysplastic hip in adolescent and young adult patients. Cite this article: Bone Joint J 2019;101-B:390–395

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. Patients and Methods. A consecutive series of 28 092 neonates was screened and classified according to the Graf method as part of a nationwide surveillance programme, and then followed prospectively. Abnormal hips were followed until they became normal (Graf type I). Type IIb hips and higher grades were treated by abduction in a Tübinger orthosis until normal. Dislocated hips underwent closed or open reduction. Results. Overall, 90.2% of hips were normal at birth. Type IIa hips (8.9%) became normal at a median of six weeks (interquartile range (IQR) 6 to 9). Type IIc and IId hips (0.67%) became normal after ten weeks (IQR 7 to 13). There were 19 type lll and eight type lV hips at baseline. There were 24 closed reductions and one open reduction. No late presentations of DDH were detected within the first five years of life. Conclusion. The incidence of DDH was eight per 1000 live births. The treatment rate was 1% (n = 273). The rate of first operations on the newborn hip was 0.86, and rate of open surgery was 0.04. The cumulative rate of open surgery was 0.07. The authors take the view that early identification and treatment in abduction of all dysplastic hips in early childhood reduces the rate of open reduction and secondary DDH-related surgery later in life. Cite this article: Bone Joint J 2018;100-B:1399–1404

Aims. The purpose of this study was to evaluate whether an innovative templating technique could predict the need for acetabular augmentation during primary total hip arthroplasty for patients with dysplastic hips. Patients and Methods. We developed a simple templating technique to estimate acetabular component coverage at total hip arthroplasty, the True Cup: False Cup (TC:FC) ratio. We reviewed all patients with dysplastic hips who underwent primary total hip arthroplasty between 2005 and 2012. Traditional radiological methods of assessing the degree of acetabular dysplasia (Sharp’s angle, Tönnis angle, centre-edge angle) as well as the TC:FC ratio were measured from the pre-operative radiographs. A comparison of augmented and non-augmented hips was undertaken to determine any difference in pre-operative radiological indices between the two cohorts. The intra- and inter-observer reliability for all radiological indices used in the study were also calculated. Results. Of the 128 cases reviewed, 33 (26%) needed acetabular augmentation. We found no difference in the median Sharp’s angle (p = 0.10), Tönnis angle (p = 0.28), or centre-edge angle (p = 0.07) between the two groups. A lower TC:FC ratio was observed in the augmented group compared with the non-augmented group (median = 0.66 versus 0.88, p <  0.001). Intra-observer reliability was found to be high for all radiological indices analysed (interclass correlation coefficient (ICC) > 0.7). However, inter-observer reliability was more variable and was only high for the TC: FC ratio (ICC > 0.7). Conclusion. The TC: FC ratio gives an accurate estimate of acetabular component coverage. It can help predict which dysplastic hips are likely to need acetabular augmentation at primary total hip arthroplasty. It has high intra- and inter-observer reliability. Cite this article: Bone Joint J 2017;99-B:445–50

The April 2013 Children’s orthopaedics Roundup. 360 . looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes

In a longitudinal case-control study, we followed 81 subjects with dysplasia of the hip and 136 control subjects without dysplasia for ten years assessing radiological evidence of degeneration of the hip at admission and follow-up. There were no cases of subluxation in the group with dysplasia. Neither subjects with dysplasia nor controls had radiological signs of ongoing degenerative disease at admission. The primary radiological discriminator of degeneration of the hip was a change in the minimum joint space width over time. There were no significant differences between these with dysplasia and controls in regard to age, body mass index or occupational exposure to daily repeated lifting at admission. We found no significant differences in the reduction of the joint space width at follow-up between subjects with dysplasia and the control subjects nor in self-reported pain in the hip. The association of subluxation and/or associated acetabular labral tears with dysplasia of the hip may be a conditional factor for the development of premature osteoarthritis in mildly to moderately dysplastic hips

Ideal placement of the acetabular component remains elusive both in terms of defining and achieving a target. Our aim is to help restore original anatomy by using the transverse acetabular ligament (TAL) to control the height, depth and version of the component. In the normal hip the TAL and labrum extend beyond the equator of the femoral head and therefore, if the definitive acetabular component is positioned such that it is cradled by and just deep to the plane of the TAL and labrum and is no more than 4mm larger than the original femoral head, the centre of the hip should be restored. If the face of the component is positioned parallel to the TAL and psoas groove the patient specific version should be restored. We still use the TAL for controlling version in the dysplastic hip because we believe that the TAL and labrum compensate for any underlying bony abnormality. . The TAL should not be used as an aid to inclination. Worldwide, > 75% of surgeons operate with the patient in the lateral decubitus position and we have shown that errors in post-operative radiographic inclination (RI) of > 50° are generally caused by errors in patient positioning. Consequently, great care needs to be taken when positioning the patient. We also recommend 35° of apparent operative inclination (AOI) during surgery, as opposed to the traditional 45°. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):37–43

Aims. Femoroacetabular impingement (FAI) has been highlighted and well documented primarily in Western countries and there are few large studies focused on FAI-related morphological assessment in Asian patients. We chose to investigate this subject. Patients and Methods. We assessed the morphology of the hip and the prevalence of radiographic FAI in Japanese patients by measuring predictors of FAI. We reviewed a total of 1178 hips in 695 men and 483 women with a mean age of 58.2 years (20 to 89) using CT images that had been obtained for reasons unrelated to symptoms from the hip. We measured the lateral centre edge angle, acetabular index, crossover sign, alpha angle and anterior femoral head-neck offset ratio. Results. A total of 441 hips (37.4%) had pincer-type deformity (41.7% men, 31.3% women) and 534 (45.3%) had cam-type deformity (54.4% men, 32.3% women). Moreover, 773 hips (65.6%) had at least one parameter that predisposes to FAI (74.0% men, 53.6% women) and 424 hips (36.0%) had two or more parameters (43.6% men, 25.0% women). Conclusion. The prevalence of radiographic FAI was common in Japanese patients who are generally considered to have dysplastic hips. Cite this article: Bone Joint J 2016;98-B:1167–74

Between 1978 and 1997 all newborns in the Austrian province of Tyrol were reviewed regarding hip dysplasia and related surgery. This involved a mean of 8257 births per year (7766 to 8858). Two observation periods were determined: 1978 to 1982 (clinical examination alone) and 1993 to 1997 (clinical examination and universal ultrasound screening). A retrospective analysis compared the number and cost of interventions due to hip dysplasia in three patient age groups: A, 0 to < 1.5 years; B, ≥ 1.5 to < 15 years; and C, ≥ 15 to < 35 years. In group A, there was a decrease in hip reductions from a mean of 25.2 (. sd. 2.8) to 7.0 (. sd. 1.4) cases per year. In group B, operative procedures decreased from a mean of 17.8 (. sd. 3.5) to 2.6 (. sd. 1.3) per year. There was a 75.9% decrease in the total number of interventions for groups A and B. An increase of €57 000 in the overall cost per year for the second period (1993 to 1997) was seen, mainly due to the screening programme. However, there was a marked reduction in costs of all surgical and non-surgical treatments for dysplastic hips from €410 000 (1978 to 1982) to €117 000 (1993 to 1997). We believe the small proportional increase in costs of the universal ultrasound screening programme is justifiable as it was associated with a reduction in the number of non-surgical and surgical interventions. We therefore recommend universal hip ultrasound screening for neonates

We have divided Severin group-V severely dysplastic hips with a false into three subtypes, based on the height and shape of the socket. We performed rotational acetabular osteotomy (RAO) in 19 hips in 17 young adults with a type-1 ‘low’ false acetabulum which had direct contact with the true acetabulum. This is a periacetabular osteotomy which gives acetabular coverage with articular cartilage and produces a nearly normal position of the head. Concomitant osteotomies of the proximal femur were carried out in 11 hips. We reviewed the patients clinically and radiologically at a mean of ten years (6 to 18) after operation. Of the 19 hips, 15 showed very good or good results. This operation is indicated in young adults with a dysplastic hip and a type-1 low false acetabulum. Subclassification of Severin group V is a convenient way of defining those patients who would benefit from the procedure

We evaluated 31 patients with bilateral dysplastic hips who had undergone periacetabular osteotomy for early (Tönnis grade 0 or 1) or moderate (Tönnis grade 2) osteoarthritis in one hip and total hip replacement for advanced (Tönnis grade 3) osteoarthritis in the other. At a mean follow-up of 5.5 years (2 to 9) after periacetabular osteotomy and 6.7 years (3 to 10) after total hip replacement, there was no difference in the functional outcome in hips undergoing osteotomy for early or moderate osteoarthritis and those with a total hip replacement, as determined by the Merle d’Aubigné and Postel score and the Western Ontario and McMaster Universities osteoarthritis index. More patients preferred the spherical periacetabular osteotomy to total hip replacement (53% vs 23%; p = 0.029). Osteoarthritis secondary to hip dysplasia is often progressive. Given the results, timely correction of dysplasia by periacetabular osteotomy should be considered whenever possible in young patients since this could produce a favourable outcome which is comparable with that of total hip replacement

Using radiography and computer tomography (CT) we studied the morphology of 83 hips in 69 Caucasian adults with osteoarthritis secondary to developmental dysplasia of the hip (DDH). A previously published series of 310 hips with primary osteoarthritis was used as a control group. According to the Crowe classification, 33 of the dysplastic hips were graded as class I, 27 as class II and 23 as class III or class IV. The intramedullary femoral canal had reduced mediolateral and anteroposterior dimensions in all groups compared with the control group. Only in Crowe class II hips was the femoral neck-shaft angle increased. The proximal femur had more anteversion in all the developmental dysplasia of the hip groups, ranging from 2° to 80°. Templated measurement of acetabular dimensions for plain radiography closely matched measurements taken by CT. The results of our study confirm the observations previously confined to the Japanese population

Between June 1988 and December 1997, we treated 332 babies with 546 dysplastic hips in a Pavlik harness for primary developmental dysplasia of the hip as detected by the selective screening programme in Southampton. Each was managed by a strict protocol including ultrasonic monitoring of treatment in the harness. The group was prospectively studied during a mean period of 6.5 ± 2.7 years with follow-up of 89.9%. The acetabular index (AI) and centre-edge angle of Wiberg (CEA) were measured on annual radiographs to determine the development of the hip after treatment and were compared with published normal values. The harness failed to reduce 18 hips in 16 patients (15.2% of dislocations, 3.3% of DDH). These required surgical treatment. The development of those hips which were successfully treated in the harness showed no significant difference from the normal values of the AI for the left hips of girls after 18 months of age. Of those dysplastic hips which were successfully reduced in the harness, 2.4% showed persistent significant late dysplasia (CEA < 20°) and 0.2% persistent severe late dysplasia (CEA < 15°). All could be identified by an abnormal CEA (< 20°) at five years of age, and many from the progression of the AI by 18 months. Dysplasia was considered to be sufficient to require innominate osteotomy in five (0.9%). Avascular necrosis was noted in 1% of hips treated in the harness. We conclude that, using our protocol, successful initial treatment of DDH with the Pavlik harness appears to restore the natural development of the hip to normal. We suggest that regular radiological surveillance up to five years of age is a safe and effective practice

Aims

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.

Aims

Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH.

Aims

Studies of infant hip development to date have been limited by considering only the changes in appearance of a single ultrasound slice (Graf’s standard plane). We used 3D ultrasound (3DUS) to establish maturation curves of normal infant hip development, quantifying variation by age, sex, side, and anteroposterior location in the hip.

Aims

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.

Aims

The aim of this study was to investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies. We asked: is there a difference in APP-PT between young symptomatic patients being evaluated for joint preservation surgery and an asymptomatic control group? Does APP-PT vary among distinct acetabular and femoral pathomorphologies? And does APP-PT differ in symptomatic hips based on demographic factors?

Aims

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.