Standardized In-harness Ultrasound Protocol Improves Success Rate of Brace Treatment for Dislocated Hips.

OBJECTIVE: Infant hip dislocations benefit from early detection and treatment for optimal outcomes. Prior studies have identified that there remains wide variability in the success rate of bracing between institutions. Although there are standardized methods to screen infants for hip dysplasia, there are no clear guidelines regarding how to image a child being treated for a hip dislocation with a Pavlik harness. As a result, there is substantial variability in how treatment success or failure is monitored between and within institutions. The goal of our study is to determine whether a standardized in-harness imaging protocol improves outcomes and the likelihood of successful treatment for dislocated hips being treated with the Pavlik harness. METHODS: All patients with hip dislocations and pretreatment ultrasound (US) were included from July 2018 to July 2022. A new institutional US protocol was implemented in July 2020, during which standardized in-harness imaging was obtained for patients with hip dislocations. Patients treated before the implementation of standardized in-harness imaging were categorized as nonstandardized and after implementation as a standardized group. Outcomes were compared between standardized and nonstandardized groups. P <0.05 determined the statistical significance. RESULTS: One hundred twenty-eight hips met the inclusion criteria (n = 97 patients). The mean age at diagnosis was 41.6 ± 23.4 days and was predominantly female (85.6%). There was no significant difference between the patients' demographics and baseline clinical characteristics between the standardized and nonstandardized groups. Pavlik harness success rate was significantly higher in the standardized group (85% vs 60%, P = 0.0024). Twenty-eight hips in the nonstandardized group remained dislocated and were indicated for surgical treatment, whereas only 8 hips remained dislocated in the standardized group and necessitated closed or open reduction. CONCLUSIONS: Standardization of in-harness imaging for patients undergoing treatment for developmental hip dislocations can significantly improve the Pavlik harness success rate. These findings emphasize the importance of obtaining images with the hip in flexion and abduction to prevent inadvertent stress during US evaluation for hips that have not yet stabilized, which may lead to premature cessation of the Pavlik harness. LEVEL OF EVIDENCE: Level III.

A Role for Thyroid Testing in Slipped Capital Femoral Epiphysis? 32% Rate of Abnormal Values in Tested Patients.

BACKGROUND: Hypothyroidism is a known risk factor for slipped capital femoral epiphysis (SCFE), and prior studies of hypothyroid-associated SCFE have demonstrated an incidence of up to 6%. However, there is limited evidence and no formal practice guidelines regarding whether patients presenting with SCFE should undergo screening for endocrine disorders. This study aims to investigate the incidence of abnormal thyroid function studies in patients presenting with SCFE. METHODS: This was a retrospective review of all patients aged 0 to 18 years treated for SCFE at a single pediatric hospital from January 2015 to July 2022. On presentation, patients' BMI, thyroid-stimulating hormone (TSH), free T4, vitamin D, creatinine, BUN, and HbA1c levels were documented. Follow-up and treatment for any identified endocrinopathies were noted. In addition, the chronicity, stability, and severity of their slips were recorded. RESULTS: Ninety-eight patients with 106 hips were included in this study. TSH was obtained at the time of initial presentation in 66% (n=65/98) of patients. Median TSH was 2.99 (range: 0.02 to 919, std dev: 132.4). The normal reference range for our institution is 0.5 to 4.5 mcIU/mL. Thirty-two percent (n=21/65) of patients with a documented TSH had an abnormal value. Of those patients who had an elevated TSH, 3 were diagnosed with clinical hypothyroidism and went on to treatment with levothyroxine (n=3/19, 16%), 2 patients had been started on levothyroxine before presentation (n=2/19, 11%), and 2 patients were followed in endocrinology clinic until their TSH levels had normalized without further intervention (n=2/19, 11%). CONCLUSIONS: Screening of our SCFE population revealed a 32% incidence of thyroid abnormalities which affected treatment in 24% of those patients. This is a much higher incidence of hypothyroid-associated SCFE than previously demonstrated in the literature and has prompted us to start including thyroid screening studies as a routine part of our workup for all patients with SCFE. LEVEL OF EVIDENCE: Level III.

Hip Pain in Adolescent Patients.

Hip pain is a common complaint in adolescents. There are several causes for hip pain in this population, with dysplasia and impingement being the most common; however, other conditions such as extra-articular impingement, torsional disorders, labral tears, and osteochondral lesions also require consideration. Many of these conditions are related to underlying anatomic abnormalities and increased activity in this age group. An understanding of the common pathologies of the adolescent hip is integral to the evaluation, diagnosis, and treatment of these patients.