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).

Conclusion

Our study reports the longest follow-up addressing the question of a potential protective effect of the ossific nucleus on the development of AVN. We could not demonstrate such an effect. Strategies aimed at delaying the treatment of a dislocated hip in the absence of the ossific nucleus cannot be recommended as they will not affect the risk for subsequent AVN.

Purpose of study

Results clinically & statistically of a 10 year prospective observational longitudinal study of the effects of sonographic screening for ‘risk’ factors in DDH.

Methods & Results

From 1997 to 2006 the project analysed the results of a sonographic screening programme for clinical instability & ‘risk factors’ in Blackburn (modified Graf system). ‘Risk factors’ included: breech presentation, strong family history, foot deformities & oligohydramnios. Statistically 95% confidence intervals, relative risk, sensitivity, specificity PPV & NPV were calculated. The outcome measure was irreducible dislocation of the hip joint. There was a birth population of 37,510, of which 2693 were ‘at risk’ & 132 clinically unstable.

Three subsections:

The overall irreducible dislocation rate was 0.51 per 1000 live births.

‘Risk factors’: mGraf Type III/IV/ Irreducible:

Narrow 95% CI for Breech, CTCV & CTEV

Wide 95% CI for Family history, oligohydramnios & TEV (postural)

95% CI (RR) for Oligohydramnios & TEV not significant.

RR for clinical hip instability was 983.6

Percentage female

34.15% of clinically unstable hip joints had a ‘risk factor’

Purpose

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

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

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

Conclusion

In this study, the sonographic information only led to a modest gain in diagnostic confidence. Ultrasound was particularly helpful for surgeons in clarifying hips with limited abduction or signs of leg length difference.

Purpose of Study

To evaluate the results of using external fixation to stabilise femoral derotation osteotomy involved in DDH surgery.

Methods and results

A retrospective analysis was performed on 44 patients undergoing 48 femoral osteotomies for DDH surgery between the years 2001 and 2009 by a single surgeon (senior author MC). The external fixator was used either during the primary procedure involving femoral shortening to aid in hip reduction (4 patients) or to correct femoral malrotation in a reduced hip as a secondary procedure(40 patients). As the external fixator frame was within the hip spica it was not a cause of concern to the parents or the child.

There was no evidence of any pin tract infection and all patients eventually progressed to satisfactory bony union. One patient had delayed union which was treated successfully with conservative management and one patient had a malunion requiring a further osteotomy and extended treatment with the external fixator.

Purpose of Study

To assess the radiological outcomes of medial screw epiphyseodesis of the proximal femoral physis in the management of lateral growth arrest following treatment of developmental dysplasia of the hip.

Methods

We identified 10 patients noted to have lateral growth disturbance of the proximal femoral physis, 9 of which were managed with medial screw epiphyseodesis. Serial radiographs were reviewed. A new technique was employed to monitor progression of lateral growth arrest and also to assess the role of screw epiphyseodesis in preventing further deterioration or indeed allowing for improvement. This method involved calculating the tilt angle (angle formed between a horizontal reference line and a line joining medial and lateral points of physis) and following its progression with increasing age.

Purpose of the study

To report the difference in the rates of avascular necrosis (AVN) of the femoral head following change in the hip abduction angle in the hip spica.

Methods

Up until 2002, following closed and medial open reduction of the dislocated hip, the joint was immobilised in a 90° of flexion, 60° of abduction and 10-20° of internal rotation hip spica. The practice was changed after 2002 to 45° of hip abduction in the spica with other parameters remaining same.

We audited the rates of radiologic AVN in these two groups of children. Group A, before 2002, had 20 children and in group B, after 2002 till Aug 2007, had 53 children. AVN was quantified on 2 year radiograph by the classification described by Salter and noted its progression on serial radiographs.

Purpose

To determine whether radiographically demonstrated femoral neck irregularities (pistolgrip-deformity, focal prominences or lytic defects) are associated with positive clinical impingement tests.

Methods

The 1989 Bergen birth cohort (n=4004) was invited to a population-based follow-up including clinical examination and two pelvic radiographs. 2081 (52%) were enrolled. Associations between clinical and radiographic findings were examined using chi-squared or Fischer's exact test.

Purpose

Clinical coding is used to record information from patient admissions in the form of coded data used for monitoring the provision of health services and trends, research, audit and NHS financial planning.

Method

A sample of 105 cases admitted to Southampton General paediatric orthopaedic department from 2006-9 was used. 31 admissions were grouped using HRG4 and the remaining 74 using HRG3.5. Accuracy of coding was calculated by establishing correct discharge coding and comparing them with coding records. The correct codes were run through HRG 3.5 and 4 payment groupers and their outcomes were compared financially to the HRG codes these admissions were actually grouped under.

Purpose of study

The results clinically & statistically of a 14 year longitudinal study comparing the traditional ‘stretch & strap’ method (1994-2002) with the Ponseti technique (2002-2008)

Methods & Results

A 14 year prospective longitudinal comparative study was undertaken into management and outcome of CTEV. There were 114 feet (80 patients), 64 feet (45 patients) treated traditionally and 50 feet (35 Patients) with the Ponseti technique. Patient demographics, the Harold & Walker Classification, and associated risk factors for CTEV were analysed. If conservative treatment failed a radical sub-talar release operation (RSR) was undertaken.

The incidence of fixed CTEV was 1.6 per 1000 live births with a male to female ratio of 2.8 to 1. Idiopathic CTEV was present in 77.5% of patients, (22.5% with a primary aetiology). Mean time to RSR was comparable: 37.43 weeks (CI: 33.65 to 41.21) and 46 weeks (CI: 39.18 to 52.82) for the traditional and Ponseti groups respectively. In the traditional group 65.6% (CI: 53.4 to 76.1%) of feet underwent RSR surgery compared to just 25.5% (CI: 15.8 to 38.3%) in the Ponseti group, When idiopathic CTEV was analysed separately these rates reduce to 56.5% (CI: 42.3 to 69.8%) and 15.8% (CI: 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR surgery in traditional compared to Ponseti groups was 2.58 (CI: 1.59 to 4.19) for all patients and 3.58 (CI: 1.65 to 7.78) for idiopathic CTEV (statistically significant). The results of the Ponseti method improved with time suggesting a learning curve.

Purpose of the study

We describe a new technique of talar dome osteotomy in the treatment of fixed equinovalgus deformity of the foot in patients with Fibular Hemimelia and successfully applied it in two patients.

Background

Fibular Hemimelia is a congenital absence or hypoplasia of fibula with associated fixed equinovalgus deformity of the foot. Treatment for this deformity ranges from corrective osteotomy of the tibia, calcaneum to Syme's amputation.