Splinting for the non-operative management of developmental dysplasia of the hip (DDH) in children under six months of age.

BACKGROUND: Developmental dysplasia of the hip (DDH) describes the abnormal development of a hip in childhood, ranging from complete dislocation of the hip joint to subtle immaturity of a hip that is enlocated and stable within the socket. DDH occurs in around 10 per 1000 live births, though only one per 1000 are completely dislocated. There is variation in treatment pathways for DDH, which differs between hospitals and even between clinicians within the same hospital. The variation is related to the severity of dysplasia that is believed to require treatment, and the techniques used to treat dysplasia. OBJECTIVES: To determine the effectiveness of splinting and the optimal treatment strategy for the non-operative management of DDH in babies under six months of age. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, seven other electronic databases, and two trials registers up to November 2021. We also checked reference lists, contacted study authors, and handsearched relevant meetings abstracts. SELECTION CRITERIA: Randomised controlled trials (RCTs), including quasi-RCTs, as well as non-RCTs and cohort studies conducted after 1980 were included. Participants were babies with all severities of DDH who were under six months of age. Interventions included dynamic splints, static splints or double nappies (diapers), compared to no splinting or delayed splinting. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and performed risk of bias and GRADE assessments. The primary outcomes were: measurement of acetabular index at years one, two and five, as determined by radiographs (angle): the need for operative intervention to achieve reduction and to address dysplasia; and complications. We also investigated other outcomes highlighted by parents as important, including the bond between parent and child and the ability of mothers to breastfeed. MAIN RESULTS: We included six RCTs or quasi-RCTs (576 babies). These were supported by 16 non-RCTs (8237 babies). Five studies had non-commercial funding, three studies stated 'no funding' and 14 studies did not state funding source. The RCTs were generally at unclear risk of bias, although we judged three RCTs to be at high risk of bias for incomplete outcome data. The non-RCTs were of moderate and critical risk of bias. We did not undertake meta-analysis due to methodological and clinical differences between studies; instead, we have summarised the results narratively. Dynamic splinting versus delayed or no splinting Four RCTs and nine non-RCTs compared immediate dynamic splinting and delayed dynamic splinting or no splinting. Of the RCTs, two considered stable hips and one considered unstable (dislocatable) hips and one jointly considered unstable and stable hips. No studies considered only dislocated hips. Two RCTs (265 babies, very low-certainty evidence) reported acetabular index at one year amongst stable or dislocatable hips. Both studies found there may be no evidence of a difference in splinting stable hips at first diagnosis compared to a strategy of active surveillance: one reported a mean difference (MD) of 0.10 (95% confidence interval (CI) -0.74 to 0.94), and the other an MD of 0.20 (95% CI -1.65 to 2.05). Two RCTs of stable hips (181 babies, very low-certainty evidence) reported there may be no evidence of a difference between groups for acetabular index at two years: one study reported an MD of -1.90 (95% CI -4.76 to 0.96), and another study reported an MD of -0.10 (95% CI -1.93 to 1.73), but did not take into account hips from the same child. No study reported data at five years. Four RCTs (434 babies, very low-certainty evidence) reported the need for surgical intervention. Three studies reported that no surgical interventions occurred. In the remaining study, two babies in the dynamic splinting group developed instability and were subsequently treated surgically. This study did not explicitly state if this treatment was to achieve concentric reduction or address residual dysplasia. Three RCTs (390 babies, very low-certainty evidence) reported no complications (avascular necrosis and femoral nerve palsy). Dynamic splinting versus static splinting One RCT and five non-RCTs compared dynamic versus static splinting. The RCT (118 hips) reported no occurrences of avascular necrosis (very low-certainty evidence) and did not report radiological outcomes or need for operative intervention. One quasi-RCT compared double nappies versus delayed or no splinting but reported no outcomes of interest. Other comparisons No RCTs compared static splinting versus delayed or no splinting or staged weaning versus immediate removal. AUTHORS' CONCLUSIONS: There is a paucity of RCT evidence for splinting for the non-operative management of DDH: we included only six RCTs with 576 babies. Moreover, there was considerable heterogeneity between the studies, precluding meta-analysis. We judged the RCT evidence for all primary outcomes as being of very low certainty, meaning we are very uncertain about the true effects. Results from individual studies provide limited evidence of intervention effects on different severities of DDH. Amongst stable dysplastic hips, there was no evidence to suggest that treatment at any stage expedited the development of the acetabulum. For dislocatable hips, a delay in treatment onset to six weeks does not appear to result in any evidence of a difference in the development of the acetabulum at one year or increased risk of surgery. However, delayed splinting may reduce the number of babies requiring treatment with a harness. No RCTs compared static splinting with delayed or no splinting, staged weaning versus immediate removal or double nappies versus delayed or no splinting. There were few operative interventions or complications amongst the RCTs and the non-randomised studies. There's no apparent signal to indicate a higher frequency of either outcome in either intervention group. Given the frequency of this disease, and the fact that many countries undertake mandatory DDH screening, there is a clear need to develop an evidence-based pathway for treatment. Particular uncertainties requiring future research are the effectiveness of splinting amongst stable dysplastic hips, the optimal timing for the onset of splinting, the optimal type of splint to use and the need for 'weaning of splints'. Only once a robust pathway for treatment is established, can we properly assess the cost-effectiveness of screening interventions for DDH.

Congenital Talipes Equinovarus: Results of Treatment and Are We Bracing Effectively?

The aim of this retrospective study was to assess our management of Congenial Talipes Equinovarus (CTEV) in relation to national standards published by the British Society for Children's Orthopaedic Surgery (BSCOS). A secondary aim was to evaluate if a more tailored bracing regime than advocated in the traditional Ponseti technique, would be appropriate for some cases of CTEV. One hundred and thirty-three feet in 96 patients were treated between June 2006 and January 2016. All patients were clinically assessed prospectively by the senior author at initial presentation using the Harrold & Walker classification system. A combination of the senior author's database, Elogbook and trust IT systems were used for data collection. The results of Ponseti surgical procedures such as tendoachilles release and tibialis transfer fell within the BSCOS guidelines. The rate of radical subtalar surgical release was higher than advocated (12.3%) which was partly due to the number of primary syndromal patients in the series. There was a significantly lower mean time spent in bracing of 14.3 months (95% confidence interval 14.8-19.3) compared to recommended national guidelines. There was a clinically significant difference in the lower relapse rate of female patients compared to male patients and also a higher propensity of surgical intervention in male patients. In addition, there was a statistically significant difference in both time spent in bracing, between H&W classifications and between patients who had bracing removed pre walking age or post walking age. This potentially demonstrates a more tailored bracing regime may be possible when applied to less severely affected feet and the condition may be more benign in female cases.

Evaluation of primary care 6- to 8-week hip check for diagnosis of developmental dysplasia of the hip: a 15-year observational cohort study.

BACKGROUND: The current 6- to 8-week Newborn and Infant Physical Examination (NIPE) clinical assessment is a current standard hip-screening test in the community (England) to detect developmental dysplasia of the hip (DDH). AIM: To assess the value of the primary care 6- to 8-week clinical hip examination for the diagnosis of DDH. DESIGN AND SETTING: A single-centre 15-year observational cohort study at a district general hospital between 1 January 1996 and 31 December 2010. METHOD: Those referred by the GP or community practitioner with suspected instability or abnormality of the hip joint (DDH), were clinically and sonographically examined in a specialist hip-screening clinic. Modified Graf Type III and IV, and radiological irreducible hip dislocation were considered to be 'pathological' hips. Screening failures were defined as those who had not been identified by this primary care screening assessment (but had irreducible hip dislocation). Secondary univariate and multivariable analyses were performed to determine which clinical findings are predictive of instability. RESULTS: Over the study period, there were 70 071 infants who underwent the 6- to 8-week clinical hip assessment. In the specialist hip-screening clinic, six (from the 170 referred) were diagnosed with pathological DDH. The sensitivity, specificity, positive predictive value, and negative predictive value for the 6- to 8-week clinical hip assessment were 16.7%, 99.8%, 3.5%, and 100.0%, respectively. A multivariable model showed a positive Ortolani manoeuvre to be the sole independent predictor of instability at 6 to 8 weeks. CONCLUSION: This 15-year study highlights the limitations of a hip check at 6 to 8 weeks. These findings support the reassessment of the national guidelines for this aspect of the NIPE DDH screening programme.

Defining the Core Components of a Clinical Review of People Using Continuous Positive Airway Pressure Therapy to Treat Obstructive Sleep Apnea: An International e-Delphi Study.

STUDY OBJECTIVES: Guidelines recommend regular review of individuals using continuous positive airway pressure (CPAP) to treat obstructive sleep apnea but do not agree on the core components and frequency. We aimed to achieve consensus on essential components and frequency of review. METHODS: We used an e-Delphi approach, recruiting a multidisciplinary international expert panel to identify components based on a list compiled from guidelines and to score these on a scale 1 to 5 over three rounds. Consensus was defined as ≥ 75% agreement for scores of 4 or higher. Free-text comments were thematically analyzed. RESULTS: Forty participants completed 3 rounds scoring 36 potential components. Seventeen components achieved consensus: treatment acceptability, sleep quality, symptom resolution (including reduction in apnea-hypopnea index), assessment of sleepiness (including when driving), technical CPAP issues (mask fit/humidification/cleaning/filters), recording CPAP adherence, and quality of life. Participants suggested 12 to 18 monthly reviews (more frequent when commencing CPAP) or "on demand." Free-text comments highlighted that reviews should be multidisciplinary, flexible (including telehealth), and focus on symptom control. CONCLUSIONS: We mapped 17 prioritized components to a suggested template that may support clinical reviews. Reviews should be flexible, frequently in the early stages of commencing CPAP, shifting to "on demand" and/or remote follow-up for maintenance. Our findings may inform future guideline recommendations for reviewing CPAP users.

Screening in Developmental Dysplasia of the Hip (DDH).

Screening for Developmental Dysplasia of the Hip (DDH) is a controversial subject. Screening may be by universal neonatal clinical examination (Ortolani or Barlow manoeuvres) with the addition of sonographic imaging of the hip (selective 'at risk' hips or universal screening in the neonate). In the UK, the NIPE guidelines recommend universal neonatal clinical assessment of the hip joints, a General Practitioner 6-8 week clinical 'hip check' and assessment clinically with sonographic imaging at 4-6 weeks for certain 'at risk' hips for pathological DDH. The effectiveness and difficulties arising from the UK current screening policy (clinical and sonographic) are highlighted. The purpose of the review was to assess the risk factors and efficacy of diagnostic methods in DDH, based on longitudinal cohort studies of 10 years or more. CONCLUSION: Hip screening in DDH does not meet most of the World Health Organisation's criteria for an effective screening programme and should only be considered as surveillance due to its low sensitivity and positive predictive value (PPV). There is a significant risk of over diagnosis and over treatment. There is no International consensus on screening in DDH. Pathological DDH is mainly a female condition and 'at risk'/General Practitioner screening identifies few pathological cases in male subjects. The General Practitioner 6-8 week 'hip check' has a very low PPV for pathological DDH and is of doubtful value in screening and diagnosis. Unilateral limitation of hip abduction is a time dependent and useful clinical sign in the diagnosis of pathological DDH. The majority of the previously considered 'at risk' factors are not true risk factors with little or no association with pathological DDH.

Pavlik harness treatment for pathological developmental dysplasia of the hip: meeting the standard?

In the UK, the Pavlik harness is generally the accepted treatment technique for the treatment of neonatal and infant pathological developmental dysplasia of the hip. In 2013, the success rate of the Pavlik harness became an outcome measure from the British Society of Children's Orthopaedic Surgery for appraisal and revalidation with the GMC for paediatric orthopaedic surgery. The standard set requires an 80% success rate, with less than 20% requiring surgery. This study evaluated the outcomes of Pavlik harness treatment in neonates/infants with 'pathological hips' diagnosed by ultrasound imaging in a district general hospital setting. In a 10-year prospective observational longitudinal cohort study, modified Graf type III and IV hips (excluding those presenting with irreducible hip dislocation) were classified as pathological and splinted. A total of 2826 neonates/infants underwent ultrasound assessment in the paediatric orthopaedic 'screening clinic'. Neonates and infants were referred as 'at-risk' or as clinically unstable by the Paediatric Department and by general practitioners. Thirty-one Graf type III and 95 Graf type IV hips were identified and treated with a Pavlik harness. One Graf type III (30/31=success rate 96.8%) and three clinically unstable Graf type IV hips progressed to irreducible hip dislocations (92/95=96.8%). The success rate of the Pavlik harness in Graf type III and IV dysplasia was 96.8%, with 3.2% requiring surgery because of progression of the condition, confirming acceptable results for this technique in a district general hospital setting.

MRI versus computed tomography as an imaging modality for postreduction assessment of irreducible hips in developmental dysplasia of the hip: an interobserver and intraobserver reliability study.

Following surgical reduction of an irreducible hip in developmental dysplasia of the hip, imaging is required to ascertain successful reduction. Recent studies have compared MRI versus computed tomography (CT) in terms of cost, time, sensitivity and specificity. This is the first study to compare intraobserver and interobserver reliability for both modalities. Nineteen CT scans of 38 hips in 10 patients and nine MRI scans of 18 hips in six patients were reviewed on two separate occasions by three clinicians. Image clarity, confidence of diagnosis, time taken to perform the scan as well as radiation dose for CT were recorded. Intraobserver and interobserver reliability κ values were calculated. There were 14 female patients and one male patient. The mean age at the time of the scan was 12 months (range 3-25 months). Intraobserver reliability was greater than 0.8 (both CT and MRI). Interobserver reliability was greater than 0.8 (both CT and MRI). Image clarity was higher for CT for two out of the three clinicians (9.47 vs. 6.33 P<0.05; 9.89 vs. 8.11, P<0.05). All clinicians were equally confident in the diagnosis when using CT or MRI. The time taken to perform the investigation was not significantly different (3.32 vs. 4.88 min, P>0.05). The mean radiation dose for CT was 91.75 DLP (dose length product, mGy×cm) (95% confidence interval±26.95). Our results show that MRI is equal to CT as an imaging modality in the assessment of postreduction hips in developmental dysplasia of the hip. Intraobserver and interobserver reliability was excellent for both. The image clarity was higher for CT, but this method of imaging carries a significant risk of radiation exposure. We recommend that MRI should supersede CT as an imaging modality for this clinical situation.

MRSA screening in orthopaedic surgery: clinically valuable and cost effective? A prospective analysis of 8,867 patients.

This study aimed at assessing the prevalence of MRSA colonisation in Trauma and Orthopaedics. Risk factors, decolonisation, and subsequent infection rates were investigated. Cost-analysis of the MRSA screening program was performed. The validity and effectiveness of the MRSA screening program was reviewed. A prospective analysis was made of all orthopaedic admissions in East Lancashire Hospital Trust. A total number of 13,155 swabs were taken in 8,867 patients in 2010. This MRSA screening program was compared to the ideal screening criteria set out by Wilson and Junger (WHO 1968). The MRSA prevalence in Trauma and Orthopaedics in 2010 was 0.47%. The decolonisation rate was 55%. There was no correlation between MRSA colonisation and subsequent infection. The total cost of MRSA screening at ELHT was calculated as a minimum of 184,170 Pounds. This could extrapolate to a national expense of around 16 million pounds in England and Wales in Orthopaedics alone. The MRSA screening program did not meet 4 out of 9 screening criteria of Wilson and Junger. The vast majority of Trauma and Orthopaedic patients are not at risk of MRSA colonisation or infection and therefore should not be screened. MRSA infection is a risk in certain high risk groups which should be screened. The MRSA screening program is ineffective when assessed to WHO standards. The program should be considered to be surveillance of MRSA, not an effective screening program for pathological MRSA infection.

Screening of selected risk factors in developmental dysplasia of the hip: an observational study.

BACKGROUND: Developmental dysplasia of the hip (DDH) is the most common neonatal musculoskeletal condition. In 2008, the NHS Newborn and Infant Physical Examination committee added selective 'at risk' screening to the existing universal neonatal and general practitioner clinical hip screening guidelines. OBJECTIVE: Assessment of breech and family history risk factors in DDH. DESIGN: A 15 year prospective, observational, longitudinal cohort study. METHOD: Breech presentation and evidence of a strong family history for DDH were the 'risk factors' studied. All infants referred were clinically and sonographically screened by one consultant paediatric orthopaedic surgeon. RESULTS: From a cohort of 64 670 live births, 2984 neonates/infants, 46.1 (95% CI 44.6 to 47.8) per 1000 live births, were referred and sonographically screened with these risk factors alone. 1360 were male, of which four were identified as having 'pathological' DDH (an incidence of 0.003 (95% CI 0.001 to 0.008)). 1624 were female, of which 45 were identified as having 'pathological' DDH (an incidence of 0.028 (95% CI 0.021 to 0.037)). This difference in incidence of 0.025 (95% CI 0.016 to 0.033) was statistically significant (p<0.001). From those who were clinically stable and screened with either or both of the two risk factors, four individuals were diagnosed with irreducible hip dislocation (0.06 (95% CI 0.024 to 0.159) per 1000 live births). All were females. CONCLUSIONS: This study questions the current UK screening policy for DDH in clinically stable males referred with risk factors, and may influence future DDH screening programme policy.

Vitamin D: a poor screening tool for biochemical and radiological rickets.

This retrospective study aims to determine if a relationship exists between serum 25-hydroxyvitamin D level and the diagnosis of biochemical or radiological rickets in children with bone and joint pain, muscle fatigue or varus/valgus knees. A retrospective biochemistry database and case note study was undertaken on 115 new patients referred to the senior authors' elective Paediatric Orthopaedic Clinic in 2010. Their mean age was 10.95 years (95% CI 10.24-11.68). Mean serum vitamin D was 18.27 mcg/l (95% CI 16.13-20.41), while 30 mcg/l is the normal threshold. One hundred and three children (88%) had vitamin D levels below normal. Winter/springtime blood samples were more likely to be deficient and this was statistically significant. Three Asian females (2.61%) were diagnosed with radiological rickets. Vitamin D levels below normal are common in children presenting with vague limb or back pain, but this rarely presents with biochemical or radiological rickets. Serum vitamin D level is not a suitable screening tool for biochemical or radiological rickets. Vitamin D requirement in children is unclear and requires further study.

Beware the syndrome in neonatal hip instability: follow up assessment is required after apparent resolution.

Developmental dysplasia of the hip is one of the most common congenital musculoskeletal disorders of childhood, affecting 1-3% of newborns. An early diagnosis and prompt treatment is essential to avoid complex treatments and achieve improved results. Since 1992, we have undertaken a screening programme for clinical instability and at risk patients. During this time, there have been only two cases which have been normal on both clinical, and, static and dynamic ultrasound assessment, that have subsequently deteriorated. In these two cases there was an underlying syndrome associated with hyperlaxity, which behaves unpredictably compared to 'true' developmental dysplasia of the hip. In conclusion, if a hip has been referred as unstable but it is found to have a primary syndromal cause (especially if hyper lax) with sonographically normal hips at one to two weeks of age, it is best to review clinically and sonographically at 6 weeks and 3 months of age to confirm that the hip is maintaining stability.

A 14-year longitudinal comparison study of two treatment methods in clubfoot: Ponseti versus traditional.

The optimal management of idiopathic clubfoot has changed over three decades. Recently there has been an enthusiastic embracing of the Ponseti technique with a move away from the traditional stretch and strap technique. The purpose of this 14-year comparative prospective longitudinal study was to directly assess the differences in results between these two treatment methods. Over the period of this study there were 52,514 births in the local population and all newborns with clubfoot were referred directly to the paediatric orthopaedic surgeon. Patient demographics, the Harrold & Walker Classification, and associated risk factors for clubfoot were collected prospectively and analyzed. If conservative treatment failed to correct the deformity adequately, a radical subtalar release (RSR) was undertaken (the primary outcome measure of the study). There were 114 feet (80 patients): 64 feet treated 'traditionally' and 50 feet with the Ponseti technique. Idiopathic clubfoot was present in 76.25% of patients. Mean time to RSR was 333 and 44.1 weeks 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 25.5% (CI : 15.8 to 383%) in the Ponseti group. When idiopathic clubfoot alone was analysed, these rates reduce to 56.5% (CI: 423 to 69.8%) and 15.8% (CI: 7.4 to 30.4%) respectively. The Relative Risk of requiring RSR 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 clubfoot. Introduction of the Ponseti technique into our institution significantly reduced the need for RSR in fixed clubfoot.

The presentation of rickets to orthopaedic clinics: return of the English disease.

Rickets is a potentially treatable disease of the bone that is most commonly due to deficiency of vitamin D and is increasing in incidence in developed countries. Risk factors include dietary factors, the practice of covering up and darker skin pigmentation. This small retrospective case study set out to examine all cases of rickets presenting to the Paediatric Orthopaedic clinic over a 15-month period. Rickets presented in a bimodal fashion in the 6 cases identified: in males and females aged 3 or less and female adolescents aged 10 and above. This is in keeping with what is known regarding the rapid phases of growth during development. Five cases were from ethnic minority groups. Both female adolescents presented with genu valgum. Rickets can present primarily to Orthopaedic clinics with vague musculoskeletal symptoms. We recommend that biochemical screening be performed on patients from ethnic minorities who may be 'at risk'.

Incidence and aetiology of talipes equino-varus with recent population changes.

This study looks at the changing incidence and aetiology of congenital talipes equinovarus due to the recent population changes within the area. Between 1st June 1992 and the 31st May 2006, 83 consecutive children (121 feet) born with fixed talipes equinovarus (TEV) were assessed and treated (an incidence of 1.6 per 1000 live births) in an observational longitudinal cohort study assessing associated factors. There were 17 syndromal cases in the fixed group (20.8%), 6 cases of non-syndromal distal arthrogryposis (7.2%), and a strong family history in 12 cases (14.5%). This study would suggest that genetic and primary causes of fixed TEV are more common than previously considered. Many of the primary aetiologies were diagnosed months or years after birth.

Bone and joint tuberculosis in children in the Blackburn area since 2006: a case series.

This report describes a series of four cases of children between the ages 5 and 14 years with bone or joint infection with Mycobacterium tuberculosis diagnosed between June 2006 and March 2008 in the Blackburn area of England. All of the cases were of South Asian descent. The diagnosis was confirmed by the presence of M. tuberculosis on the culture of bone, synovium or joint fluid, or by the presence of the typical histology of tuberculosis (TB). The sites of tuberculous disease were the hip joint, the sacro-iliac joint and the talus. A recent paper by Sandher et al. (J Bone Joint Surg Br 89:1379-1381, 2007) illustrated only two cases of childhood bone and joint TB in the same geographical area in the preceding 17 years.

Turner syndrome - an accidental finding?

We report the case of a 9-year-old girl with bilaterally reduced pedal pulses following emergency surgery for unilateral subtrochanteric femoral fracture. This incidental postoperative finding of differential blood pressures between the upper and lower limbs led to the diagnosis of aortic coarctation and subsequent karyotype analysis confirmed the rare diagnosis of Turner syndrome.

Congenital pseudarthrosis of the clavicle: the role of CT-scanning.

Congenital pseudarthrosis of the clavicle is a rare entity. It presents on the right side in 90% of the patients, and bilaterally in up to 10%. The authors report the case of a 4-year-old boy who presented with a painful deformity over his right mid-clavicular area. Plain radiographs were inconclusive, although the opposite is true in most cases. A computed tomography (CT) 3-D reconstruction showed a pseudarthrosis of the clavicle, and excluded a neoplastic, infective or traumatic origin. Treatment involved excision of the pseudarthrosis, internal fixation with a contoured reconstruction locking plate, and bone grafting. The authors prefer operative treatment, but this is not universally accepted.

Serial casting in the treatment of idiopathic toe-walkers and review of the literature.

Idiopathic toe-walking is defined as persistent toe-walking in a normal child in the absence of developmental, neurological or neuromuscular conditions. True idiopathic toe-walking is a rare referral, representing approximately 1:100 new patients seen in the Paediatric Orthopaedic Clinic. A prospective study of idiopathic toe-walking (ITW) was organised between 1999 and 2003. Patients underwent full history, neurological examination and assessment of ankle dorsiflexion, followed by below-knee weight-bearing casting. Forty four developmentally normal children with no delay in walking age were in this study. There was an age range on presentation from 2 years to 14 years 4 months, with median 60.5 months. Sixty eight percent were male. Thirty four percent had a family history of the condition. Following casting, 66% of patients had improved gait on patient and clinician determined outcomes, with the majority of children ceasing to toe-walk. Ankle dorsiflexion significantly improved in those children who were successfully treated (p = 0.001).

Management of neonatal hip instability and dysplasia.

The diagnosis and treatment of neonatal hip instability and dysplasia is controversial. Different countries have different algorithms and guidelines on which hips should be screened or treated. German speaking countries have introduced universal ultra sound hip screening programmes resulting in relatively high splintage rates in certain centres. Some Scandinavian centres have organised selective screening programmes with serial ultrasound observation of hip instabilities, leading to comparatively low splintage rates. Though most experts would treat clinical hip instability (confirmed by ultrasound evaluation), the natural history and epidemiology of dysplasia is less well understood. The treatment regimes for neonatal dysplasia are varied with wide differences in the rates of splintage. 'Late' dislocation may be secondary to prenatal dislocation (teratogenic), neonatal hip instability or to persistent major dysplasia of the hip. The term 'missed' dislocation should not be used as this suggests negligence on the part of the examiner, when this may not be the case. Which splint to use (rigid or dynamic), at what age, and for how long, are questions currently unresolved as no proper controlled trials have been undertaken. However, a sensible treatment algorithm can be advocated. Complications secondary to splintage are rare, though nerve damage, avascular necrosis of the hip, redislocation and skin problems have been described.